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

May 2019

Updates to Electronic Authorization & Use of InterQual®

In addition to the HPHConnect enhancements we’ve announced (new home and resource pages, as well as referral page updates), Harvard Pilgrim is updating our electronic authorization screens and expanding our use of InterQual® criteria and tools beginning on July 15, 2019.

Our electronic authorization screens will be updated with a more streamlined look that is even easier for users to navigate and added functionality to support the changes detailed below.

InterQual® criteria and tools

Harvard Pilgrim will be expanding our use of InterQual® criteria and tools for select commercial prior authorization policies. In some cases, we are adopting existing InterQual® criteria and in others the criteria more closely, or entirely, reflects our existing Harvard Pilgrim criteria.

Additionally, for all the policies noted below, we have partnered with InterQual® to create electronic authorization questionnaires (a variation of InterQual’s PDF Smartsheets). When providers or office staff enter their request for authorization electronically in HPHConnect, they will be brought automatically to the electronic questionnaire to answer a series of questions to help determine medical necessity.

Having this information available at the time of the request enables a quicker, more efficient authorization determination. For some services, providers may need to submit images, photographs, or clinical documentation in addition to completing the questionnaire.

While Harvard Pilgrim encourages providers to request authorization electronically, we will continue to accept authorization requests by phone (800-708-4414) or fax (800-232-0816).

Affected medical policies

For dates of service beginning July 1, 2019, the following commercial prior authorization policies will be updated as part of this initiative:

Please select the policy above to view the medical criteria; note, however, that any proprietary InterQual® information will appear on HPHConnect rather than the policy displayed on our public provider website. Beginning July 1, you may access this information as follows: Log in to HPHConnect and then select Resources and the InterQual® link. Or you may contact the commercial Provider Service Center at 800-708-4414.

New feature for submitting documentation
launches on July 1

As noted above, for these and other policies, providers are sometimes required to submit photographs, images or clinical documentation for Harvard Pilgrim to make a medical necessity determination. Beginning July 1, you’ll be able to submit your clinical documentation through a new Clinical Upload feature. When entering your authorization request, you’ll see the “Clinical Upload” button, which will enable you to easily attach any required images or clinical documentation. After July 1, we encourage you to submit your documentation electronically, but clinical information can be supplied in any of the following ways:

  • Clinical notes/written documentation — via HPHConnect Clinical Upload or secure fax (800-232-0816)
  • Photographs — HPHConnect Clinical Upload function, email (utilization_requests@harvardpilgrim.org), or mail (Utilization Management, 1600 Crown Colony Dr., Quincy, MA 02169). Please note that photographs should not be faxed as faxed photos cannot be utilized in making a medical necessity determination.

Education & training

We will offer a variety of training materials and webinars to walk you and your office staff through these changes and ensure that you have all the information you need — including screenshots, as well as a user guide, quick reference guide, FAQ, and training presentation.

Look to future issues of Network Matters, as well as the HPHConnect homepage, for more information.

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Robert Farias,
Senior Vice President, Corporate Network Strategy

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator