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Medicare Advantage Prior Authorization Forms


Prior Authorization Request Forms

When making a request for prior authorization, please complete the applicable form and fax it to 866-874-0857. For most prior authorization requests, you will need to complete the general Medicare Advantage Prior Authorization Request Form.

For some services, however, you will need to complete a more specific prior authorization form. Harvard Pilgrim has developed the following customized prior authorization forms to ensure that we obtain the clinical information necessary so that we may process your request quickly and efficiently:

In addition, beginning February 1, 2016, Harvard Pilgrim will require prior authorization for diagnostic imaging services and select spinal surgeries and injections. Utilization management for these services will be managed by National Imaging Associates, Inc. (NIA). For more information, please refer to the Spine Management and Prior Authorization Policy.

As of January 1, 2016, Harvard Pilgrim does not require prior authorization for Medicare Advantage Stride members the following procedures:

  • Cataract surgery
  • Colonoscopy
  • Sleep studies

For more information on prior authorization policies and procedures, please refer to the Access to Care section of the Medicare Advantage Provider Manual.


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Key Resources

Medicare Advantage Provider Portal

Medicare Advantage Provider Portal Registration Form

Quick Reference Guide

Stride (HMO) Medicare Advantage Prior Authorization and Referral Chart

Prior Authorization Request Forms

Referral Form

Claims Appeal Form

Medicare Compliance Program

Medicare Advantage Provider Service Center:
Phone:
888-609-0692
Monday–Friday,
8:30 a.m. to 5 p.m.

To mail Medicare claims:
Harvard Pilgrim Health Care, Inc.
c/o Stride Claims Processing
P.O. Box 151288
Tampa, FL 33684-1288

Claims appeal:
Medicare Advantage Provider Appeals
P.O. Box 690546
Quincy, MA 02169