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

September 2017

Prior Authorization for Select Hip, Knee, and Shoulder Surgeries


Effective Dec. 11, 2017, Harvard Pilgrim is requiring prior authorization through National Imaging Associates, Inc. (NIA) for the following non-emergent inpatient and outpatient hip, knee, and shoulder surgeries for commercial members enrolled in our HMO, PPO, and POS products:

Hip

  • Revision/conversion hip arthroplasty
  • Total hip arthroplasty/resurfacing
  • Femoroacetabular impingement (FAI) hip surgery (includes CAM/pincher & labral repair)
  • Hip surgery – other (includes synovectomy, loose body removal, debridement, diagnostic hip arthroscopy, and extra-articular arthroscopy knee)

Knee Revision Knee Arthroplasty 

  • Total knee arthroplasty (TKA)
  • Partial-unicompartmental knee arthroplasty (UKA)
  • Knee manipulation under anesthesia (MUA)
  • Knee ligament reconstruction/repair
  • Knee meniscectomy/meniscal repair/meniscal transplant
  • Knee surgery – other (includes synovectomy, loose body removal, diagnostic knee arthroscopy, debridement with or without chondroplasty, lateral release/patellar realignment, articular cartilage restoration)

Shoulder Revision Shoulder Arthroplasty

  • Total/reverse shoulder arthroplasty or resurfacing
  • Partial shoulder arthroplasty/hemiarthroplasty
  • Shoulder rotator cuff repair
  • Shoulder labral repair
  • Frozen shoulder repair/adhesive capsulitis
  • Shoulder surgery – other (includes debridement, manipulation, decompression, tenotomy, tenodesis, synovectomy, claviculectomy, diagnostic shoulder arthroscopy)

Harvard Pilgrim chose to partner with NIA due to their clinical expertise in musculoskeletal management. As part of this program, Harvard Pilgrim will transition any knee, hip, or shoulder surgery prior authorization requirements that we are currently managing directly (including hip and knee arthroplasty) to NIA. In addition, Harvard Pilgrim is re-introducing prior authorization for knee arthroscopy due to practice pattern variability across our markets.

Requesting authorization

The ordering clinician is responsible for obtaining prior authorization through NIA before scheduling the outpatient, nonemergent procedures detailed in our Hip/Knee/Shoulder Surgery Prior Authorization Policy and medical review criteria. Any of these non-emergent services performed on or beyond Dec. 11, 2017 will not be reimbursed if a prior authorization was not obtained. Therefore, to ensure payment of the claim, providers rendering these services should verify that the necessary prior authorization has been obtained prior to performing the procedure by requiring evidence of an approved NIA transaction number.

NIA currently provides utilization management for Harvard Pilgrim for radiology, select spine services, and sleep studies, and ordering providers should request prior authorization for hip, knee, and shoulder surgeries in the same way:

  • Online at www.radmd.com
  • By telephone at 800-642-7543 (Monday-Friday, 8 a.m. to 8 p.m. EST)

Providers may begin making prior authorization requests for hip, knee, and shoulder surgeries through NIA on Nov. 27, 2017 for dates of service of Dec. 11, 2017 and beyond.

As noted earlier, Harvard Pilgrim currently requires prior authorization for several procedures that will be transitioning into the NIA managed hip, knee, and shoulder surgery program; in these cases, providers should continue to request prior authorization through Harvard Pilgrim until Nov. 27, 2017, at which time they should contact NIA for prior authorization.

Harvard Pilgrim does not require prior authorization for emergent procedures that are admitted through a hospital emergency room.

Updated policies and criteria

For more information, including coding, please refer to the following:

Please refer to next month’s issue of Network Matters for more information and resources, including a checklist, an FAQ, and webinar information. If you have any further questions, please contact the Provider Service Center at 800-708-4414.

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