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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

February 2017

Prior Authorization for Non-Emergent Transportation


Effective for dates of service beginning May 1, 2017, Harvard Pilgrim is requiring prior authorization for all non-emergent transportation, including air (fixed-wing) and ground transportation (i.e. ambulance, wheelchair van). Prior authorization is not required for emergency transportation that is reasonable and medically necessary to ensure the member’s safe transport to the nearest medical provider capable of furnishing covered services.

In January, Harvard Pilgrim began requiring prior authorization for non-emergent transportation for Medicare Advantage members, and this policy extends the requirement to commercial plans.

Coverage and criteria

The updated Medical Transportation Medical Review Criteria outlines the criteria that must be met to receive prior authorization. Under this policy, the following codes require prior authorization: A0130, A0426, A0428, and A0430. While the following mileage codes do not require prior authorization, Harvard Pilgrim will only provide reimbursement for them when a prior authorization has been obtained for the corresponding transport service: A0425, A0435, and S0209.

Among the criteria, Harvard Pilgrim provides coverage for reasonable, medically necessary ground transportation to ensure the member’s safe transport only from the origins/destinations listed below.

Origin 

Destinations

  • Member’s home/ place of residence (e.g., private residence/domicile, assisted living facility, long-term care facility, skilled nursing facility at a custodial level of care).
  • An acute care hospital, inpatient rehabilitation facility (IRF), or long term acute care hospital (LTAC)
  • Inpatient hospice
  • Skilled nursing or subacute facility
  • Dialysis facility (only when the individual's condition at the time of transport requires ambulance services).

NOTE: The presence of end-stage renal disease and/or the requirement for chronic hemodialysis alone do not meet criteria for ambulance transport services. To be considered reasonable and necessary, members transported to and from hemodialysis centers must have other conditions such as those described within this policy.

  • Member’s home
  • An acute care hospital, inpatient rehabilitation facility (IRF), or LTAC
  • Inpatient hospice
  • Skilled or subacute nursing facility
  • Dialysis facility (only when the individual's condition at the time of transport requires ambulance services).

In addition, medically necessary transportation to a physician’s office or free-standing facility may be covered only when transportation origin is a skilled nursing or sub-acute facility, or an acute rehabilitation facility or LTAC where the member is being treated at a skilled level of care.

For complete criteria for non-emergent fixed-wing air, ground, or wheelchair van, please refer to the updated Medical Transportation Medical Review Criteria. In addition, the Ambulance Transport Payment Policy has been updated.

Requesting Prior Authorization

The member’s ordering provider is responsible for requesting the authorization with Harvard Pilgrim. To request prior authorization, please complete the Transportation Prior Authorization Request Form and submit your request to Harvard Pilgrim’s Referral/Authorization Unit using one of the following methods:

  • Electronically via HPHConnect or NEHEN
  • Fax:  800-232-0816
  • Telephone: 800-708-4414

Transport providers should confirm that an authorization has been approved using HPHConnect or calling the telephone number listed above.

Use Participating Ambulance Providers

As a reminder, it’s important to use a Harvard Pilgrim contracted ambulance provider when coordinating ambulance services for our members. Using ambulance services that do not participate in Harvard Pilgrim’s network can result in higher out-of-pocket costs for your patients, affect risk-sharing arrangements, and increase the overall cost of health care premiums.

Harvard Pilgrim has a robust network of participating ambulance providers, which you can find in its entirety in our Provider Directory. When delivering care to Harvard Pilgrim members, please select an ambulance provider from this directory.

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