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

November 2018

Highlights
Harvard Pilgrim Regional Network Meeting: Manchester NH Kickoff Event

Harvard Pilgrim is pleased to announce our new network engagement series — and we’re excited to invite our New Hampshire providers and office staff to our first event in Manchester on Dec. 5.

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Prior Authorization for Cervical Spine Procedures

Harvard Pilgrim is expanding our existing musculoskeletal (MSK) prior authorization program with National Imaging Associates, Inc. (NIA) to include non-emergent inpatient and outpatient cervical spine surgeries for commercial and Medicare Advantage members. Effective for dates of service beginning Jan. 1, 2019.

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Medicare Advantage: Cardiac Prior Authorization Program

For dates of services beginning Jan. 1, 2019, Harvard Pilgrim will require prior authorization for Medicare Advantage members for certain non-emergent cardiac diagnostic tests and interventional procedures through National Imaging Associates, Inc. (NIA).

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Updates on Medical Drugs Obtained Through Specialty Pharmacy

As you may know, Harvard Pilgrim Health Care makes select medical drugs available through both the buy and bill process and specialty pharmacy to allow members and providers greater choice and convenience.

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Billing Monitored Anesthesia Care Policy for Screening Colonoscopies for Commercial Members

Under our commercial Monitored Anesthesia Care (MAC) for Gastrointestinal Endoscopic Procedures policy, Harvard Pilgrim covers MAC for screening colonoscopies without cost sharing for members, in keeping with provisions of the Patient Protection and Affordable Care Act.

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Update to Reimbursement Process for Observation to Inpatient Transition

Harvard Pilgrim has updated the commercial reimbursement process for observation stay and inpatient admissions for facilities reimbursed via the percent-of-charge methodology, in an effort to improve efficiency and simplify the administrative experience for these providers.

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HPHCURRENT EVENTS

Harvard Pilgrim Regional Network Meeting: Manchester NH Kickoff Event

CLINICIAN CORNER

Prior Authorization for Cervical Spine Procedures

Medicare Advantage: Cardiac Prior Authorization Program

New Emergency Room Cost Sharing Structure for New Hampshire Plans

Updates on Medical Drugs Obtained Through Specialty Pharmacy

Billing Monitored Anesthesia Care Policy for Screening Colonoscopies for Commercial Members

Billing Diagnosis Codes for Preventive Services

Newly Covered Codes for Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

Updates to Rituxan Medical Review Criteria

Generic Form of Makena Now Covered

Diabetes Prevention and Management Programs and Resources

New Pharmacy Prior Authorizations for 2019

Pharmacy and Therapeutics Committee Meeting Update

OFFICE ASSISTANT

Update to Reimbursement Process for Observation to Inpatient Transition

Modifier SA for Reporting on Behalf of Non-Physician Practitioners

PUBLICATION INFORMATION

Robert Farias,
Senior Vice President, Corporate Network Strategy

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator