On an ongoing basis, Harvard Pilgrim reviews our medical policies to ensure that they reflect the most current evidence-based clinical guidelines and support care that is medically necessary, clinically effective, and cost efficient. As a result of this review, Harvard Pilgrim is creating medical criteria for 7 surgical procedures.
Effective for dates of service on or after July 1, 2015, Harvard Pilgrim will require prior authorization for the following procedures (please click on the links to see the detailed medical review criteria):
Our medical review policies provide detailed information on what Harvard Pilgrim covers, what documentation is necessary for prior authorization, and associated coding. These policies were developed after Harvard Pilgrim’s medical management team conducted a rigorous analysis of the clinical literature with input from practicing specialists in the field. “As we developed these policies, we collaborated with board-certified practicing physicians in the community who had expertise in these areas,” says Dr. Michael Sherman, Harvard Pilgrim’s chief medical officer. “Their input was invaluable in helping us draft surgical policies that ensure that care is effective and consistent with evidence-based medicine and established clinical guidelines.”
To request prior authorization, please enter the information about the procedure into our e-business web-based transaction tool HPHConnect or NEHEN and submit the appropriate prior authorization form (these will be posted on June 15) and medical documentation required (listed in the online medical review criteria) by fax to Harvard Pilgrim’s utilization management team at 800-232-0816. Authorization requests will be reviewed by Harvard Pilgrim’s trained nurse and physician reviewers. You can check the status of your prior authorization request through HPHConnect or NEHEN. Visit Harvard Pilgrim’s provider website to register for HPHConnect.