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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:

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

StrideSM (HMO) Medicare Advantage Prior Authorization and Referral Chart

Prior Authorization Request Forms

Referral Form

Claim Review Form

Claims Appeal Form

Claim Overpayment Refund Form

Medicare Compliance Program

Drug Formulary and Utilization Management Criteria


Prior Authorization Requirements

Step Therapy Requirements

Medicare Prescription Drug Coverage Determination Form

Medicare Advantage Provider Service Center:
Oct. 1 – March 31,
8 a.m. to 5 p.m. (ET), 7 days a week
April 1 – Sept. 30,
8 a.m. to 5 p.m. (ET), Monday - Friday

To mail Medicare claims:
Harvard Pilgrim Health Care, Inc.
c/o Stride Claims Processing
P.O. Box 93430
Lubbock, TX 79493

Claims appeal:
Fax#: 617-509-4225, or mail to: Medicare
Advantage Provider Appeals
P.O. Box 690546
Quincy, MA 02169