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Referral/Authorization Quick Reference Guide

This information represents requirements for the standard HMO1, POS, and PPO products. Products may vary by employer group and state. No guarantee of payment is implied. Use this guide as a quick reference tool, only. Consult the Provider Manual for specific product and service requirements or call the Provider Service Center at 800-708-4414.

1For the Connecticut Open Access HMO product, no referral is required to see a contracted specialist.

2R = Referral; N = Notification; A = Authorization
3MRC = Prior Auth Medical Review Criteria; NP = Notification Policy; AP = Authorization Policy; PAF = Prior Authorization Request
Form; MAPAF = Massachusetts Standard Form for Medication Prior Authorization

Access Harvard Pilgrim's Provider Manual for a detailed list of all products and service requirements at www.harvardpilgrim.org/providers.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

SERVICE
(See below for abbreviations)2
HMO and In-Network POS PPO and Out-of- Network POS RESOURCES
(See below for abbreviations)3

Allergy Injections (specialist services)

R none • MAPAF

Ambulance Transport — for all non-emergent transportation

A

A • MRC
• PAF

Artificial Cervical Disc Replacement

A

A National Imaging Associates (NIA) conducts utilization management review.
Refer to NIA website (www.radmd.com) or call NIA at 800-642-7543.

Bariatric Surgeries

A

A • MRC
• PAF

Behavioral Health/Substance Abuse Services

  • Behavioral Health/Substance Abuse Services
    • Non-Routine Outpatient Services including: 
    • Intensive Treatment Programs
    • Partial Hospitalization and Day Treatment Programs
    • Electroconvulsive Treatment (ECT)
    • Psychological and Neuropsychological Assessment
    • Transcranial Magnetic Stimulation (TMS)
    • Extended visits (> 45-50 minutes/session)
    • Treatment involving more than 1 visit/day
  • Non-emergent Inpatient Admissions
  • Ongoing Inpatient Care

Contact Harvard Pilgrim Behavioral Health Access Center at 888-777-4742.

A

A • MRC
• AP

Bone Marrow Transplant/Stem Cell Transplant (Inpatient
Admissions)

N

Breast Surgeries

  • Breast Implant Removal
  • Breast Reconstruction
  • Breast Reduction Surgery (reduction mammoplasty)
  • Inverted Nipple Repair (Other nipple procedures are covered only when they are a medically necessary part of an authorized breast reconstruction procedure, and relevant HPHC Medical Review Criteria are met.)

A

A • MRC

Bronchial Thermoplasty

A

A • MRC
• PAF

Bunionectomy

A

A • MRC

Cardiac diagnostic tests/interventional procedures (select, non-emergent)

none

none Refer to NIA website (www.radmd.com) or call NIA at 800-642-7543.

Cardiac Rehabilitation (outpatient)

none

none

Cervical Spine Surgery (Eff. 1.1.19)

A

A Refer to NIA website (www.radmd.com) or call NIA at 800-642-7543.

Chiropractic Services

none

none

Cholecystectomy

A

A • MRC
• PAF

Selected Cosmetic and Reconstructive Surgeries

  • Eye procedures — (blepharoplasty, brow ptosis repair,
    blepharoptosis repair)
  • Nasal procedures — (rhinoplasty, septoplasty, rhinophyma
    treatment)
  • Skin procedures — (scar revision, treatment of hemangiomas
    and port wine stains)
  • Repair of Congenital Chest Deformities — (pectus carinatum,
    pectus excavatum, Poland Syndrome)

A

A • MRC

Cochlear Implants

A

A • MRC
• PAF

Cryotherapy — Prostate Cancer

A

A • MRC
• PAF

Dental/Oral Surgery Services

• MRC
• PAF
• AP

Diabetes Management System

A

A • MRC
• PAF

Dialysis (outpatient)

none

none

Durable Medical Equipment (DME)

  • Physician’s order required for all DME
  • Authorization required for:
    • Continuous Glucose Monitoring Systems
    • Sleep therapy equipment
    • Prosthetic Devices (upper and lower limbs)
    • Miscellaneous DME (i.e., HCPCS code E1399 or A9999)

Authorization
required for
all items provided
to HMO
members by
non-contracted
vendors/
providers

• AP

Early Intervention Services

none

none

Early Maternity Discharge Visit

none

none

Emergency Ambulance — Air or Ground Transport

none

none

Emergency Dental Care (accidental injury)

none

none

Emergency Room Services

none

none

Enteral Formulas

A

A • MRC
• PAF

Extended Care Facility

  • Skilled Nursing Facility & Subacute Care
  • Inpatient Rehabilitation/Long-Term Acute Care

A

A

  • MRC (Skilled Nursing Facility & Subacute Care)
  • MRC (Inpatient Rehabilitation/
  • Long-Term Acute Care)
  • PAF

Fecal Bacteriotherapy

A

A

Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures

none

none

Gender Reassignment Surgeries

A

A • MRC

Genetic and Molecular Diagnostic Testing

A

A • MRC
• AP

AIM Specialty Health® (AIM) manages HPHC's genetic testing authorization program.
Refer to AIM's website at
www.aimspecialtyhealth.com or by telephone at 855-574-6476.

Gynecomastia Surgery

A

A

• MRC

Harvard Pilgrim HMO, Best Buy HMO, and Tiered Copay
HMO Plans with Focus NetworkSM — MA Limited Network
Option

Refer to
product
pages

Refer to
product
pages
Product Portfolio: Product and Product Administration — HMO Plans

Hereditary Breast/Ovarian Cancers Genetic Testing

A

A

Select Hip Surgeries

A

A National Imaging Associates (NIA) conducts utilization management review. Refer to NIA website (www.radmd.com) or call NIA at 800-642-7543.

Home Health Care

A

A

• MRC
• AP

Hospice Care

A

A

• MRC

Home Infusion

A

A

• MRC

Human Organ Transplant

N

N

Hysterectomy

A

A • MRC
• PAF

Immune Globulin

A

A • MRC

Implantable Neurostimulators — (deep brain stimulators,
gastric stimulators, sacral nerve stimulators, spinal cord
stimulators, Vagus Nerve stimulators)

A

A • MRC
• PAF

Infertility Services (MA)

A

A

• MRC
• PAF
• AP

Separate authorizations required for PGD testing and embryo biopsy through AIM (see Molecular Diagnostics Medical Review Criteria) before submitting IVF authorization request to HPHC

Infertility Services (CT)

A

A

• MRC
• PAF
• AP 

Separate authorizations required for PGD testing and embryo biopsy through AIM (see Molecular Diagnostics Medical Review Criteria) before submitting IVF authorization request to HPHC

Inpatient Consultations

none

none

Inpatient Medical and Surgical Admissions

N (for most
services).
Authorization
required for
admissions for
services on
Harvard Pilgrim’s
Focused
Review List
(see Prior Authorization
Policy

for more
information).

N (for most
services).
Authorization
required for
admissions for
services on
Harvard Pilgrim’s
Focused
Review List
(see Prior Authorization
Policy

for more
information).
Varies by service. Please refer to prior authorization form criteria at www.harvardpilgrim.org/providers.

Interventional Spine Pain Management procedures for
Back Pain including:

  • Epidural Injections
  • Facet Joint Injections
  • Facet Neurolysis

A

A

• AP

National Imaging Associates (NIA) conducts utilization management review. Refer to NIA website (www.radmd.com) or call NIA at
800-642-7543.

Intra-facility Transfer

A

A • AP

Intravenous Antibiotics for treatment of Lyme Disease

A

A • MRC

Hyaluronate Preparations for Osteoarthritis of the Knee

A

A

• MRC

Hip/Knee/Shoulder Surgeries

A

A

• AP

National Imaging Associates (NIA) conducts utilization management review. Refer to NIA website(www.radmd.com) or call NIA at 800-642-7543.

Laboratory Tests (outpatient)

none

none

Low Protein Food (state–mandated)

none

none

Lumbar Spine Surgery including:

  • Lumbar Fusion — Single and Multiple Level
  • Lumbar Decompression
  • Lumbar Microdiscectomy

A

A

• MRC
• AP

National Imaging Associates (NIA) conducts utilization management review. Refer to NIA website (www.radmd.com) or call NIA at 800-642-7543.

Medical Drugs — Select

A

A Medical Drug Program
CVS Health–NovoLogix conducts utilization management review for select medical drugs. Submit your request to CVS Health– NovoLogix via phone (844-387-1435) or fax (844-851-0882). See policies and forms here.

Medical Transport — for all non-emergent transportation including fixed-wing air and ground

A

A • MRC
• PAF

Neonatal Intensive Care — Notification is required for all non-routine newborn care (level ll - lV) admissions on or after date of service 04/15/17.

N

N • NP

Neonatal Well Care (inpatient)

none

none

Non-Participating Provider (inpatient/outpatient) — Emergent/urgent

N

N

Non-Participating Provider (inpatient/outpatient) — Elective

A

N (for inpatient
admissions
and
Focused
Review List
services)
• AP

Nutritional Counseling

none

none

Observation Stay

none

none

Obstetric and Gynecologic Services (outpatient)

none

none

Obstetrical Admissions

none

none

Obstructive Sleep Apnea/Obstructive Sleep Disorders Surgeries:

  • Maxillomandibular Advancement (MMA)/Mandibular
    Advancement (MA)
  • Uvulopalatopharyngoplasty (UPPP)
  • Genioglossus Advancement/Hyoid Suspension

A

A • MRC

Occupational Therapy — Initial visit

none

none • PAF
• AP

Occupational Therapy — Subsequent visits for "Visit Limit" Plans

N

N • PAF
• AP

Occupational Therapy — Subsequent visits for "Per
Condition" Plans

A

A • PAF
• AP

Oral Surgery (hospital-based)

A

A • MRC
• AP
• PAF

Oral Surgery (office-based)

R

none • MRC

Oral Surgery — Tooth extraction only (office-based)

none

none • MRC

Out of Network Referrals

A

none • MRC
• Referral Policy

Panniculectomy/Removal of Excess Skin

A

A • MRC

Participating Physician Specialist Services

R

none

PCP Coverage (outside member’s local care unit)

R

none

Physical Therapy — Initial visit

none

none • PAF
• AP

Physical Therapy — Subsequent visits for "Visit Limit" Plans

N

N • PAF
• AP

Physical Therapy — Subsequent visits for "Per
Condition" Plans

A

A • PAF
• AP

Preimplantation Genetic Testing

A

A

• AP

AIM Specialty Health® (AIM) manages HPHC's genetic testing authorization program.
Refer to AIM's website at
www.aimspecialtyhealth.com or by telephone at 855-574-6476.

Prenatal Care (outpatient)

none

none

Prescriptions

A

A • MAPAF

Private Duty Nursing

A

A (Not covered under most Harvard Pilgrim
plans.)

Podiatry/Foot Care

R

none

Prosthesis Coverage

A

A • MRC (upper)
• MRC (lower)

Professional Component of Inpatient Services (anesthesia excluding anesthesiologist pain management, diagnostic testing, emergency room treatment, radiation treatment)

none

none

Pulmonary Rehabilitation (Outpatient)

A

A • MRC
• PAF

Radiology — Outpatient Advanced Imaging including:

  • Computerized Tomography and Computerized Tomography
    Angiography (CT/CTA)
  • Magnetic Resonance Imaging and Magnetic Resonance
    Angiography (MRI/MRA)
  • Nuclear Cardiology
  • Positron Emission Tomography (PET)
  • Diagnostic CT Colonoscopy (Virtual Colonoscopy,
    CT Colonography)

A
Refer to NIA’s
website
www.radmd.com or contact
National
Imaging Associates
at 800-
642-7543

A
Refer to NIA’s
website
www.radmd.com or contact
National
Imaging Associates
at
800-642-7543
National Imaging Associates (NIA) conducts
utilization management review.
Refer to NIA website (www.radmd.com) or call NIA at 800-642-7543.

Radiology — Other Diagnostic Services

none

none

Reconstructive and Restorative Surgeries

A

A • MRC

Inpatient Rehabilitation Hospital/Long Term Acute Care
Hospital Admissions (including inpatient pulmonary rehab)

A

A • MRC
• AP

Routine Physical Exams & Sick Visits by member’s PCP

none

none

Second Opinion

R

none

Sinus Surgeries — (frontal sinusotomy, functional endoscopic
sinus surgery, nasal/sinus cavity debridement following
FESS, maxillary sinusotomy)

A

A • MRC
• PAF

Skilled or Sub-Acute Nursing Facility Admission

• MRC
• AP

Sleep Studies/Sleep Therapies

A

none National Imaging Associates (NIA) conducts utilization management review. Refer to NIA website (www.radmd.com) or call NIA at 800-642-7543.

Sleep Therapy Supplies — (Non-Invasive Airway Assist Devices [CPAP, APAP and BiPAP] and related sleep therapy supplies)

A

none • NP

Speech Therapy — Initial visit

none

none • PAF
• AP

Speech Therapy — Subsequent visits

A

A • PAF
• AP

Skilled Nursing Facility Admission

A

A • MRC
• NP

Spine Management and Authorization

A

A National Imaging Associates (NIA) conducts utilization management review. Refer to NIA website (www.radmd.com) or call NIA at 800-642-7543.

TMJ Surgeries

  • Therapeutic arthroscopy
  • Arthroplasty/arthrotomy including discectomy
  • Joint replacement

A

A • MRC

Transcranial Magnetic Stimulation (TMS)

A

A • MRC

Urinary Incontinence (Invasive treatment)

A

A • MRC
• PAF

Varicose Veins Treatment

A

A • MRC
• PAF

Vision (Annual Examination)

none

none

Vision Hardware for Special Conditions

N

N