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

February 2019

Reminder: UM Decision-Making and Communications


As a reminder, Harvard Pilgrim has established policies and procedures that govern our utilization management program. We will periodically share this information in Network Matters to ensure that providers are familiar with our policy and know how to access it.

As our Utilization Management Policy documents, Harvard Pilgrim makes utilization decisions that are clinically appropriate for the member and consistent with evidence-based standards of care. Harvard Pilgrim’s utilization management staff (including clinicians who make utilization-related decisions, and those who supervise them) make authorization and denial decisions based solely on medical necessity, clinical appropriateness of care, and the availability of benefits.

As a matter of policy, Harvard Pilgrim does not make decisions regarding the hiring, compensation, termination, or promotion of clinical reviewers based on the likelihood that they will support the denial of benefits. In addition, we do not reward individuals who conduct utilization review for issuing inappropriate denials (i.e., denials of coverage for appropriate, medically necessary services), or offer utilization decision-makers any financial incentives intended to reward the inappropriate restriction of care or result in under-utilization of medically necessary services.

Our utilization management reviewers and care management staff are available during regular business hours (Monday-Friday, 8:30 a.m.- 5 p.m. EST) to speak with members, practitioners, and providers seeking information about utilization management processes and/or the authorization of care. Providers seeking this information should call Harvard Pilgrim’s Provider Call Center at 800-708-4414, or our Medicare Advantage Provider Service Center at 888-609-0692.

For complete details, please read the Utilization Management Policy in our online Provider Manual (visit www.harvardpilgrim.org Provider Manual Network Operations and Care Delivery Management > Care Delivery Programs).

You can also find information on which services require prior authorization for commercial members in the Referral, Notification, Authorization section of the commercial Provider Manual and the Quick Reference Guide by Service & Product chart. For Medicare Advantage prior authorization information, please refer to the Access to Care section of the Medicare Advantage Stride Provider Manual and the Stride Prior Authorization and Referral Chart.

To ensure providers understand the basis upon which Harvard Pilgrim coverage decisions are made, clinical criteria are published on Harvard Pilgrim’s provider site at www.harvardpilgrim.org/providers. You may also obtain printed copies by contacting the Provider Service Center at 800-708-4414 (commercial products) or 888-609-0692.

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PUBLICATION INFORMATION

Robert Farias,
Senior Vice President, Corporate Network Strategy

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator