Effective July 1, 2014, Harvard Pilgrim Health Care will require prior authorization on selected spinal surgeries and injections. Harvard Pilgrim has chosen National Imaging Associates, Inc. (NIA) to provide utilization management for outpatient interventional spine pain management procedures and inpatient and outpatient lumbar surgeries for members enrolled in our HMO, POS, PPO, and Access America products. In addition to overseeing these efforts, Harvard Pilgrim will continue to be responsible for claims adjudication and medical policies.
Prior authorization and reimbursement
For Harvard Pilgrim members residing in Massachusetts, New Hampshire, Maine, Connecticut, and Rhode Island*, prior authorization will be required for the following:
- Non-emergent inpatient and outpatient spine surgeries: lumbar microdiscectomy; lumbar decompression (laminotomy, laminectomy, facetectomy, and foraminotomy); and lumbar spine fusion (arthrodesis)
- Non-emergent outpatient interventional spine pain management services: spinal epidural injections; paravertebral facet joint injections or blocks; paravertebral facet joint denervation [Radiofrequency (RF) Neurolysis]
Ordering physicians will be responsible for obtaining prior authorization for all of the procedures and spine surgeries listed above. Any of these non-emergent services performed on or beyond July 1, 2014, will not be reimbursed if a prior authorization was not obtained. Therefore, to ensure payment of the claim, providers rendering the services listed above should verify that the necessary authorization has been obtained prior to performing the procedure.
Harvard Pilgrim does not require prior authorization for emergency spine surgery cases that are admitted through an emergency room or spine surgeries outside the scope of those listed above.
For more detailed information, please refer:
NIA will offer provider training prior to implementation; look to future issues of Network Matters for more details. If you have any further questions, please contact the Provider Service Center at 800-708-4414.
*Pending regulatory approval in Rhode Island