Harvard Pilgrim is updating and clarifying our policy requiring prior authorization for non-emergent transportation for our commercial members, which went into effect in May. Harvard Pilgrim requires prior authorization for non-emergent transportation including air (fixed-wing) and ground transportation (ambulance). Prior authorization is not required for emergency transportation to ensure the member’s safe transport to the nearest medical provider capable of furnishing covered services.
Effective immediately, please note that prior authorization is not required for commercial members for the following:
- Transportation between acute care hospitals and mental health facilities (H to H)
- Transportation between acute care hospitals (H to H)
- Transportation between an acute care hospital and a long-term acute care facility (LTAC)or inpatient rehabilitation facility (IRF) [H to H]
- Wheelchair van transports
For transfers from an acute hospital to an LTAC or IRF, a wheelchair van should be utilized when possible. If a patient meets the criteria for ambulance transport and an ambulance is used, one of the following diagnosis codes (indicating the need for supervised non-emergent ambulance transport) must be included in the claim and supported by the medical chart:
- Bed confinement status (Z74.01)
- Need for continuous supervision (Z74.3)
- Physical restraint status (Z78.1)
- Dependence on other enabling machines and devices (Z99.89)
All other non-emergent transportation requires prior authorization. Harvard Pilgrim will conduct retrospective audits to ensure that any transports between acute hospitals and IRFs or LTACs meet the medical necessity criteria in the policy.
Providers coordinating transportation should utilize participating providers.
For complete information, please refer to our updated commercial Medical Transportation Medical Review Criteria, and when requesting authorization please complete the Non-Emergent Ground Transportation Prior Authorization Request Form