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

August 2018

Prior Authorization No Longer Required for Cologuard Test

In the June issue of Network Matters, Harvard Pilgrim communicated that we will no longer require prior authorization for coverage of the colorectal cancer screening test Cologuard for commercial members. This same change also applies to members of Harvard Pilgrim’s StrideSM (HMO) Medicare Advantage plans.

We have removed the following CPT code from the Stride Molecular Diagnostic Management prior authorization policy, as the test is now covered without prior authorization:

  • 81528 – Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result
As a reminder, please continue to request prior authorization for other molecular diagnostic testing for commercial and Stride members through AIM Specialty Health in one of the following ways:

For more information, refer to Harvard Pilgrim’s updated StrideSM (HMO) Medicare Advantage Molecular Diagnostic Management Medical Review Criteria.

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Network Matters Archives

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New Partnership Leverages Digital Tech for Care Management

Voluntary Home Infusion Program for Remicade and IVIG


Promote the Flu Vaccine to Your Patients for the Upcoming Season

New HCPCS Codes for Hemlibra and Luxturna

Opdivo Approved for an Additional Indication

Rebinyn and Durolane to be Covered with Prior Authorization

Prior Authorization No Longer Required for Cologuard Test

Members’ Rights and Responsibilities

Pharmacy & Therapeutics Committee Meeting Update

Recognizing Generalized Anxiety Disorder in the Primary Care Setting


Home Care Providers: Billing for Postnatal Skilled Nursing Home Visits

270/271 Eligibility Response Update and Telemedicine Billing Reminders

Billing for Facility-Based Urgent Care

QMB Members Cannot be Billed for Medicare Parts A and B Cost-Sharing


Robert Farias,
Senior Vice President, Corporate Network Strategy

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator