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

October 2017

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.

As a reminder, effective Dec. 11, 2017, Harvard Pilgrim is requiring prior authorization through NIA for select hip, knee, and shoulder surgeries for commercial members enrolled in our HMO, PPO, and POS products. In addition, prior authorization will be required for these services for our Medicare Advantage members, effective Jan. 1, 2018.

Services Requiring Prior Authorization

The following non-emergent inpatient and outpatient hip, knee, and shoulder surgeries will require prior authorization through NIA:


  • 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)

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.

Requesting authorization

The ordering clinician is responsible for obtaining prior authorization through NIA before scheduling any of these procedures. Any of these non-emergent services performed on or after the effective dates noted above 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.

Providers may request prior authorization from NIA:

  • 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 beginning Dec. 11, 2017 for commercial members and Dec. 26, 2017 for dates of service beginning Jan. 1, 2018 for Medicare Advantage members.

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

Webinars and other resources

Harvard Pilgrim and NIA are offering educational webinar sessions to providers who wish to learn more about this prior authorization program. Hour-long sessions will take place on the following dates:

  • Tuesday, Nov. 7, 2017  at 8 a.m. EST
  • Wednesday, Nov. 8, 2017 at 8 a.m. EST
  • Tuesday, Nov. 14, 2017 at noon
  • Wednesday, Nov. 15, 2017 at noon

To enroll in one of these sessions, please RSVP at least one week prior to the session you plan to attend by emailing NIAWebinar@magellanhealth.com and including the following information in your request:

  • Harvard Pilgrim webinar
  • Webinar date
  • Group name
  • TIN
  • Address
  • Phone number
  • Fax number
  • Number of participants attending from your organization

For more information on the webinars, including access instructions, please refer to this webinar invitation.

For more information, please refer to the following:

If you have any further questions, contact the Provider Service Center at 800-708-4414.

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