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

November 2015

Medicare Advantage Stride (HMO) Updates and Reminders


As the new year approaches, Harvard Pilgrim would like to share a few key updates and reminders for Medicare Advantage Stride. As described in last month’s issue, 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. Refer to this article from the October issue of Network Matters for the list of services requiring prior authorization effective January 1, 2016 and information on how to request a prior authorization.

Detailed information on the policies requiring prior authorization is available in the Medical Management section of our Provider website. In addition, an "Authorization and Referral Requirements" chart in our Provider Manual provides a summary which notes any prior authorization forms that are required. The forms are now posted, for use beginning with date of service January 1, 2016.

Referral requirements for 2016
Additionally, Harvard Pilgrim has conducted our annual review and refresh of referral requirements for our Medicare Advantage Stride (HMO) products. Effective January 1, 2016, our Medicare Advantage members will be required to get a referral from their primary care physician for the following services:

  • Chiropractic services
  • Provider specialist services excluding psychiatric services
  • Occupational therapy services
  • Physical therapy services
  • Speech language pathology
  • End stage renal disease
  • Kidney disease education services
  • Podiatry services
  • Cardiac rehabilitation services
  • Pulmonary rehabilitation services
  • Eye exams (Exception: annual eye exam)
  • Hearing exams
  • Medical nutrition therapy

How to submit a referral
To request a referral for dates of service on or after January 1, 2016, complete the Medicare Advantage Referral Form and FAX it to 888-874-0857 — or call the Medicare Advantage Provider Service Center at 888-609-0692 (TYY: 711).

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PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator