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
- 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.