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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

October 2015

Medicare Advantage Reminders: Expansion and Prior Authorization Policies

As open enrollment for Medicare Advantage Stride begins this month, we want to provide you a few updates and reminders. As we announced last month, Harvard Pilgrim is expanding the service area for our Medicare Advantage StrideSM (HMO) products from 9 to 17 counties in Massachusetts, Maine, and New Hampshire:

  • Massachusetts: Bristol, Essex, Norfolk, Plymouth, Middlesex (excluding 01824, 01826, 01863), Suffolk, and Worcester
  • Maine: Androscoggin, Cumberland, Kennebec, Sagadahoc, and York
  • New Hampshire: Cheshire, Hillsborough, Merrimack, Rockingham, and Strafford

Prior Authorization Updates
In addition, we conducted our annual review of clinical medical and prior authorization policies for our Medicare Advantage StrideSM (HMO) products and refreshed some policies to provide greater clarity on medical necessity and coverage. Effective January 1, 2016, the following services require prior authorization (consistent with policies for our commercial products):

  • Cholecystectomy
  • Continuous Glucose Monitoring Systems
  • Medicare Part B Pharmacy and Home infusion drugs including:
    • Antibiotics for the treatment of Lyme Disease
    • Antiemetics: Aloxi, Anzemet, and Emend
    • Remicade
    • Yervoy
  • Durable Medical Equipment (DME)/Prosthetics
  • Home Infusion Services
  • Gynecomastia surgery
  • Home health services
  • Hysterectomy
  • Implantable neurostimulators
  • Inpatient Rehabilitation Facilities and Long Term Acute Care Hospitals
  • Inpatient services provided during a non-covered inpatient stay
  • Medical Transportation (Non-emergent Fixed Wing Air Ambulance)
  • Reconstructive and Restorative Surgeries including:
    • Chest Procedures
    • Eye Procedures
    • Nasal Procedures
    • Skin Procedures(including Panniculectomy and Removal of Excess Skin)
  • Sinus Surgeries         
  • Skilled Nursing Facility (SNF) and Subacute Care
  • Temporomandibular Joint (TMJ) Surgeries
  • Total Ankle Replacement
  • Total Hip Arthroplasty
  • Total Knee Arthroplasty     
  • Urinary Incontinence Surgeries

Detailed information on these policies is available in the Medical Management section of our Provider website. In addition an “Authorization and Referral Requirements” chart provides a summary which notes any prior authorization forms that are required. The forms will be posted there on November 15, 2015 for use beginning January 1, 2016.

Elective inpatient admissions
Keep in mind as well that all elective inpatient admissions to acute care hospitals require prior authorization. The admitting physician or facility must FAX the prior authorization form, along with supporting clinical documentation to Harvard Pilgrim prior to the patient being admitted. Effective January 1, 2016, when a member is admitted to the hospital on an emergency basis, the servicing provider is responsible for notifying Harvard Pilgrim within 48 hours of the member’s admission.

Requesting a prior authorization
For dates of service effective January 1, 2016, to request an authorization, complete the appropriate prior authorization form and FAX it to 888-874-0857 — or call the Medicare Advantage Provider Service Center at
888-609-0692. You can also review the status of authorization requests via the Medicare Advantage Provider Portal.

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Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

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Production Coordinator