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

October 2017

Highlights
Harvard Pilgrim’s New “Estimate My Cost” Transparency Tool

Harvard Pilgrim is developing a new medical cost transparency tool, which will replace Now iKnow on Jan. 1, 2018.

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Medicare Advantage: Important Information about Jimmo Settlement

In keeping with a requirement from the Centers for Medicare & Medicaid Services (CMS), Harvard Pilgrim offers the following reminder to our Medicare Advantage providers regarding the settlement of the 2013 Jimmo v. Sebelius class action lawsuit.

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Medicare Advantage Policy Updates for 2018

Harvard Pilgrim is introducing several new policies and updating existing ones for StrideSM(HMO) Medicare Advantage members. Changes include requiring prior authorization for sleep studies; select hip, knee, and shoulder surgeries; and genetic/genomic and molecular testing, as well as updates to several existing policies.

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Prior Authorization for Hip, Knee, and Shoulder Surgeries

As a follow-up to last month’s announcement that Harvard Pilgrim is requiring prior authorization through National Imaging Associates, Inc. (NIA) for select hip, knee, and shoulder surgeries, this article provides additional information and resources, including an FAQ and webinar dates and times, and new information on the effective date for Medicare Advantage members.

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Synagis for Upcoming RSV Season

With respiratory syncytial virus (RSV) season approaching, Harvard Pilgrim would like to remind providers of our policy regarding Synagis (palivizumab), an injection of antibodies used to protect high-risk infants from severe RSV disease.

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Reporting Modifier 50 for Bilateral Procedures

We would like to offer providers a few reminders about billing for bilateral procedures.

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Network Matters Archives

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HPHCURRENT EVENTS

Harvard Pilgrim’s New “Estimate My Cost” Transparency Tool

Medicare Advantage: Important Information about Jimmo Settlement

Medicare Advantage Policy Updates for 2018

New Products and Benefits for 2018

CLINICIAN CORNER

Prior Authorization for Hip, Knee, and Shoulder Surgeries

Updates to Cholecystectomy Medical Review Criteria

Synagis for Upcoming RSV Season

Therapeutic Yoga for Chronic Pain and Other Conditions

P&T Committee Updates

Specialty Pharmacy Program Updates

ADHD Diagnosis and Follow-up Care

OFFICE ASSISTANT

Reporting Modifier 50 for Bilateral Procedures

2018 CPT and HCPCS codes

PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Senior Vice President, Network Strategy

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator