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Commercial Prior Authorization Medical Review Criteria

Harvard uses evidence-based criteria to make fair, impartial, and consistent decisions that facilitate the appropriate use of selected elective services. All criteria are reviewed/updated annually.

Criteria developed by Harvard Pilgrim (with input from actively practicing physicians in relevant specialties) are posted on this site. Proprietary (InterQual®) criteria (used to review requests for outpatient rehabilitative services, and in concurrent review of inpatient hospital care) are available, upon request, to members and providers impacted by a denial decision.

View the Prior Authorization Medical Review Forms

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