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Medical Management
Clinical Guidelines
Prior Authorization Medical Review Criteria
Injectable/Infusible Drug Medical Policies
Clinical Medical Policies
Continuity and Coordination of Care
Disease and Health Risk Management
Quality Program Initiatives
Medical Record Quality
Patient Safety
Hospital Quality
Physician Group Honor Roll
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Quality Grants Program
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Medical Management

Harvard Pilgrim offers you a wide range of medical management tools and information in support of your clinical practice. These include clinical guidelines, medical review criteria, medical policies and our preventive health and disease management programs.

Clinical Guidelines
Clinical algorithms designed to assist you in the evaluation and treatment of some of your patients' more common problems.

Prior Authorization Medical Review Criteria
Criteria used to make fair, impartial, and consistent decisions that facilitate the appropriate use of selected elective services that require prior authorization.

Clinical Medical Policies
Assessments of contemporary and emerging treatments including recommendations about patient eligibility and referral.

Injectable/Infusible Drug Medical Policies
Harvard Pilgrim's coverage guidelines for select injectable and infusible drugs.

Continuity and Coordination of Care
Policies developed to define Harvard Pilgrim's expectations regarding the continuity and coordination of care, and describe the specific mechanisms used to measure practitioners' performance related to those expectations.

Disease and Health Risk Management Programs
Population and evidence-based systematic approaches which aim to improve the medical care and self-management skills of targeted populations and to identify those at risk.

Quality Program Initiatives
Information about clinical and service quality initiatives.

Medical Record Quality
Information to support the continuous improvement of medical record documentation.

Patient Safety
Information about Harvard Pilgrim's initiatives to improve the safety of care provided to patients in inpatient and outpatient settings.

Hospital Quality
Harvard Pilgrim reviews hospital quality outcomes reported on Hospital Compare. Measures that are reviewed include those for timely and effective care, patient experience, readmissions, mortality, surgery, and health care associated infection.

Physician Group Honor Roll
Acknowledgement of the physician practices within the HPHC network that are exemplary in high levels of performance in HEDIS quality measures. See the listings of practices serving Adult and Pediatric members and the methodology used to evaluate their performance.

Quality Grants Program
Since 2000, this annual grant funding program has supported physician group initiatives to improve quality, safety, efficiency, and patient-centeredness of care provided to our members.


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Massachusetts Health Council's Health Resource Guide*
A comprehensive list of health and disease management websites.