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STRIDESM Prior Authorization Medical Review Criteria

Harvard Pilgrim Stride Medicare Advantage HMO requires prior authorization for certain elective (non-emergent) services, and uses evidence-based criteria to make fair, impartial, and consistent decisions to facilitate the appropriate use those services. All prior authorization criteria are consistent with Medicare requirements defined in CMS National Coverage Determinations (NCDs) and relevant Local Coverage Determinations (LCDs).

We use proprietary (InterQual®) criteria to review certain services (e.g., inpatient hospital care); these criteria are available, upon request, to members and providers impacted by a denial decision. For other services, we use criteria developed by Harvard Pilgrim with input from actively practicing physicians in relevant specialties. (Criteria developed by Harvard Pilgrim are posted on this site.)

All criteria are reviewed and updated annually.

Please refer to our prior authorization medical policies below for more detail:

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