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

March 2018

Updates to Formulas and Enteral Nutrition Medical Review Criteria

Harvard Pilgrim has updated our commercial Formulas and Enteral Nutrition Medical Review Criteria. The updated policy makes a distinction between oral administration and tube administration of low-protein foods, special medical formulas, and enteral nutrition, and outlines the separate coverage criteria for the two administration methods. In addition, enteral electrolyte hydration fluids and Relizorb have been added to the list of coverage exclusions.

Harvard Pilgrim has also added the following enteral formula codes to the policy, and they will now be eligible for coverage, with prior authorization: B4157; B4158; B4159; B4160; B4161; and B4162.

For complete information, please refer to Harvard Pilgrim’s updated Formulas and Enteral Nutrition Medical Review Criteria.

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New Preferred Biologics Drugs for Step Therapy

2017 Physician Group Honor Roll Announced  


Genetic Testing Authorization Updates

Update: Monitored Anesthesia Care for GI for Endoscopic Procedures

Reminder: UM Decision-Making and Communications

National Healthcare Decisions Day Emphasizes Advance Care Planning

Reminder: Refer Members to Participating Laboratories

Reminder: No Cost Share for Naloxone and Narcan Nasal Spray

Gender Reassignment Services Medical Review Criteria Updates

Updated: Invasive Treatment of Urinary Incontinence Criteria

Updates to Formulas and Enteral Nutrition Medical Review Criteria

Updates to Biofeedback Medical Policy

New Codes Covered for Varicose Veins with Prior Authorization


Reminders and Guidelines when Coding for Cancer

Enhancements to 271 Eligibility Response Transactions

Keep Panel Status and Demographic Information Up to Date

Reminder: Use the Correct Form for Provider Changes for Quicker Service


Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Senior Vice President, Corporate Network Strategy

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator