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

May 2017

Highlights
Medical Drug Prior Authorization Program with CVS Health—NovoLogix

Harvard Pilgrim has selected CVS Health–NovoLogix to oversee and expand our prior authorization program for medical drugs to optimize treatment outcomes and promote the safe and cost-effective use of these medications.

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Reminder: CVS Specialty is New Preferred Specialty Pharmacy

As we announced in last month’s issue of Network Matters, Harvard Pilgrim has selected CVS Specialty as our preferred specialty pharmacy, effective July 1, 2017.

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Update to Infliximab Medical Review Criteria

Effective for dates of service beginning May 26, 2017, Harvard Pilgrim is updating our commercial and StrideSM (HMO) Medicare Advantage medical review criteria for the medication infliximab (Remicade/Inflectra) to allow coverage for the CPT code Q5102 (Injection, infliximab, biosimilar, 10 mg).

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ACA Risk Adjustment Data Validation: Medical Chart Requests

The U.S. Department of Health and Human Services and Massachusetts Health Connector (the federal and state agencies administering the Affordable Care Act’s risk adjustment program) are required to annually validate the accuracy of claims data submitted by health insurance companies for risk adjustment-covered-plans through the validation of members’ medical records.

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2017 Home Care Seasonal Flu Vaccine Fee Schedule

Updates to Harvard Pilgrim’s standard home care seasonal influenza vaccine fee schedule will take effect on August 1, 2017.

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HPHCURRENT EVENTS

GIC Product Updates Effective July 1

CLINICIAN CORNER

Medical Drug Prior Authorization Program with CVS Health–NovoLogix

Reminder: CVS Specialty is New Preferred Specialty Pharmacy

Update to ExMI Therapy for Urinary Incontinence Medical Policy

Update to Infliximab Medical Review Criteria

Fecal Microbiota Transplantation Medical Policy Updated

Reducing Preventable Readmissions in the Medicare Advantage Population

Non-Medication Alternative Treatments for Chronic Pain

ACA Risk Adjustment Data Validation: Medical Chart Requests

Robust Discussion at Massachusetts Medical Directors’ Meeting

OFFICE ASSISTANT

2017 Home Care Seasonal Flu Vaccine Fee Schedule

PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator