For all products, when prior authorization is required, Harvard Pilgrim uses
written criteria based on sound clinical evidence to evaluate the medical appropriateness
of health care services. These criteria are objective and based on current clinical
and medical evidence, and applied with consideration of individual needs and
characteristics (e.g., age, comorbidities, prior treatment and complications),
and the availability of services within the local delivery system.
Harvard Pilgrims prior authorization requirements for commercial (HMO,
POS, PPO) products are different from the requirements for its StrideSM
(HMO) Medicare Advantage product. Please choose the appropriate product
below to view Harvard Pilgrims product-specific Medical Review Criteria.