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

April 2018

Highlights
Reminder: Medical Drugs & Buy-and-Bill or Specialty Pharmacy

As you know, Harvard Pilgrim requires prior authorization on approximately 200 medical drugs. While providers use the buy-and-bill process to obtain the majority of these drugs, a subset is available through the specialty pharmacy as well.

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Cochlear Implants to Require Prior Authorization

Effective for dates of service beginning June 1, 2018, Harvard Pilgrim will require prior authorization for cochlear implants for members in our commercial HMO, POS, and PPO products.

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Update to Bariatric Surgeries Prior Authorization Policy

Effective for dates of service beginning April 15, 2018, Harvard Pilgrim is updating our prior authorization policy for bariatric surgery to require confirmation by a specialist of the presence of certain medical conditions and completion of a medically supervised weight loss and exercise program within a given time frame.

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Substance User Disorder: Treatment and Helpful Resources

Substance abuse is a devastating and far-reaching problem, exacerbated by the fact that patients and their loved ones often do not know where to begin in addressing it — or even how to start the conversation.

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Payment Policy Updates: DME and Orthotic and Prosthetic Devices

Harvard Pilgrim regularly reviews coding practices to ensure that the care delivered to our members is represented as completely and accurately as possible.

As a result, we are making changes to the coding requirements detailed in our commercial Durable Medical Equipment (DME) and Orthotic and Prosthetic Devices payment policies, (as of 6/1/18)...

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HPHCURRENT EVENTS

Reminder: Medical Drugs & Buy-and-Bill or Specialty Pharmacy

CLINICIAN CORNER

Cochlear Implants to Require Prior Authorization

Update to Bariatric Surgeries Prior Authorization Policy

New Bunionectomy Medical Review Criteria

Harvard Pilgrim Adding Coverage for Newly Approved Medications

Tips for Efficient Pharmacy Prior Authorization Process

Complex Case Management Services

Disease Management Programs Reinforce Physician Treatment Plans

Updates to Medical Policies and Prior Authorization Criteria

Policy Update: Replacement of the First Metatarsophalangeal Joint

Updates to Implantable Neurostimulators Medical Review Criteria

Corneal Collagen Cross-Linking Now Covered

New Prior Authorization Policy for Hemlibra

New Prior Authorization Policy for Imfinzi

Substance Use Disorder: Treatment and Helpful Resources

P&T Committee Meeting Update

OFFICE ASSISTANT

Payment Policy Updates: DME and Orthotic and Prosthetic Devices

Medical Records: Common Issues and Quick Fixes

PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Senior Vice President, Corporate Network Strategy

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator