Harvard Pilgrim’s medical/clinical policies for Medicare Advantage members are available below. This list includes prior authorization criteria and policies in which prior authorization is not required; policies requiring prior authorization are designated with the PA notation below.
Harvard uses evidence-based criteria to make fair, impartial, and consistent decisions that facilitate the appropriate use of select services. All criteria are reviewed/updated annually. All prior authorization criteria are consistent with Medicare requirements defined in CMS National Coverage Determinations (NCDs) and relevant Local Coverage Determinations (LCDs).