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

June 2017

Reminder: Concurrent Review for Inpatient Stays

As a reminder, Harvard Pilgrim applies a concurrent review program for inpatient admissions to acute care hospitals, acute rehabilitation and long-term acute care hospitals, and skilled nursing facilities to ensure that our members receive evidence-based, well-coordinated, and cost effective health care.

The concurrent review process includes obtaining and utilizing clinical information provided by facility staff to determine the appropriateness of the level of care and to assist in the discharge planning process. Harvard Pilgrim’s nurse care managers conduct outreach to the appropriate staff from the facility’s case management, care coordination, or discharge planning departments by telephone beginning as early as the third day of the member’s stay.
For this review, the nurse care managers will apply InterQual Criteria, a nationally accepted standard medical necessity criteria set from McKesson/ChangeHealthcare. The nurse care managers continue the review throughout the Harvard Pilgrim member’s stay, depending on the member’s clinical status and the standards outlined in the InterQual criteria. For most members, reviews continue to occur every two days.

Harvard Pilgrim will notify facility staff of coverage determinations in a timely manner and, in certain circumstances, may refer the case for physician review. For more information on our concurrent review program, please refer to the Clinical Decisions policy in Harvard Pilgrim’s online Provider Manual.

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Network Matters Archives

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Changes to Sleep Diagnostic and Sleep Therapy Program

Review of Inpatient Admissions for Appropriate Level of Care

Reminder: Concurrent Review for Inpatient Stays

New Publication on Healthy Eating for Older Adults


Reminder: Expanded Medical Drug Prior Authorization Program

ACA Risk Adjustment Data Validation Reminder: Medical Chart Requests

Update to StrideSM (HMO) Medicare Advantage Hysterectomy Criteria

Updates to Bariatric Surgeries Medical Review Criteria

Updates to Varicose Vein Procedures Medical Review Criteria

Update to Cardiac Event Monitors Medical Policy

Prescribing Statins to Members with Diabetes

Members’ Rights and Responsibilities

Biological Effects of Cannabis and Detriments to Adolescent Development


Telemedicine/Telehealth Payment Policy

Change in Format of Newly Assigned Practitioner and Provider ID Numbers

Credentialing Reminder: Keep Provider Information Up to Date in CAQH

Keep Panel Status and Demographic Information Up to Date


Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator