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

February 2018

Highlights
Changes to Negative Balance and Refund Processes

To facilitate more timely and efficient recovery of claim overpayment amounts, Harvard Pilgrim is updating some of our negative balance and refund check processes for our commercial, Medicare Enhance, and Medicare Supplement members. Effective Feb. 1, 2018, we will begin moving some outstanding negative balances from a provider group/payee with no claims processing to another group/payee within the same provider organization (with the same TIN) that frequently has claims paid. By doing so, Harvard Pilgrim will deduct the negative balance amount from the other group’s claims paid amount.

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Maximum Dosages for Medical Drugs

As we announced in previous issues of Network Matters, effective for dates of service beginning Feb. 26, 2018, Harvard Pilgrim will apply industry standard claims edits and will not reimburse for drug dosages above limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines for the medical drugs listed here for our commercial members.

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Reminder: Prior Authorization for Genetic Testing

As a reminder, Harvard Pilgrim currently requires prior authorization for genetic testing for Medicare Advantage members, and will be expanding the program to include commercial members, effective March 1, 2018.

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Prior Authorization for Diabetes Management Devices

Effective for dates of service beginning April 1, 2018, Harvard Pilgrim is updating our commercial Continuous Glucose Monitoring Systems Medical Review Criteria, which will be renamed Diabetes Management Devices Medical Review Criteria.

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Reminder: Use the Correct Form for Provider Changes for Quicker Service

As you know, it’s critical that members have accurate information about your practice, so they can make informed decisions about their health care options.

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Network Matters Archives

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HPHCURRENT EVENTS

Changes to Negative Balance and Refund Processes

Maximum Dosages for Medical Drugs

Reminder: Prior Authorization for Genetic Testing

Saheli Boston Can Help Meet the Needs of South Asian Patients

CLINICIAN CORNER

Prior Authorization for Diabetes Management Devices

Coverage of Exondys 51 with Prior Authorization

PCP Cardiac Medication Adherence Report

Member Blood Pressure Quiz

Endoscopic Sinus Surgeries Medical Review Criteria Updates

Lyme/Tick-Borne Diseases: Use of Parenteral Antibiotics Criteria

P&T Committee Meeting Update

Specialty Pharmacy Update

Members’ Rights and Responsibilities

HEDIS Spotlight: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET)

OFFICE ASSISTANT

Reminder: Use the Correct Form for Provider Changes for Quicker Service

PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Senior Vice President, Network Strategy

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator