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
All criteria are reviewed and updated annually.