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

October 2016

Medicare Advantage Updates: Expansion and Prior Authorization Policies


As open enrollment for Stride (HMO) Medicare Advantage plan begins this month, we want to provide you a few updates, including information about our expanded service area, new product benefits for 2017, and additional prior authorization and clinical medical policies. 

Expanded service area

We’re pleased to announce that we’ve expanded the service area for our Stride (HMO) Medicare Advantage products for 2017 from 17 to 20 counties in Massachusetts, Maine, and New Hampshire:

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

New benefits for 2017

Members can choose from two plan options: Value Rx and Value Rx Plus. Both plans offer a competitive member premium, minimum PCP copays, and comprehensive benefits including: Part D Prescription drug coverage, with enhanced alternative drugs; inpatient hospital coverage; routine care and wellness visits; and annual eye exams and low-cost hearing exams. For 2017, Harvard Pilgrim’s Stride (HMO) Medicare Advantage plans will provide new and enhanced benefits including:

  • Preventive dental coverage included at no additional premium cost
  • Robust hearing aid coverage with copayments
  • An expanded $200 fitness reimbursement on all plans (now includes personal training, Yoga and CrossFit)

Prior authorization updates

In addition, after conducting an annual review of clinical literature and existing medical and prior authorization policies for our Stride (HMO) Medicare Advantage products, Harvard Pilgrim has updated some existing policies and introduced some new policies to provide greater clarity on medical necessity and coverage.

For dates of service beginning January 1, 2017, Harvard Pilgrim is introducing or updating prior authorization policies for Stride (HMO) Medicare Advantage members for the following services:

  • Bariatric surgery — Prior authorization is required for all bariatric surgery procedures. This policy clarifies when bariatric surgeries are considered medically necessary and when repeat procedures may be authorized. 
  • Dermabrasion — Prior authorization is required for all dermabrasion services.
  • Durable Medical Equipment — The existing policy is being updated to require prior authorization for single items costing $750 or more (previously the threshold was $500).
  • Medical Transportation — Prior authorization requirements are being expanded to include all non-emergent transportation, including air (fixed-wing) and ground transportation (i.e., ambulance, wheelchair van).
  • Outpatient Physical and Occupational Therapy Services — Prior authorization and submission of treatment plan will now be required after initial visit for outpatient physical and occupational therapy services.
  • Reduction Mammoplasty — Prior authorization is required for all reduction mammoplasty (breast reduction) procedures. 
  • Stelara — Prior authorization is required for all injections of Stelara (ustekinumab).
  • Varicose Vein Treatment — Policy clarifies when elective treatment of varicose veins is considered medically necessary and lists the interventional treatments for varicose veins that require prior authorization.
These policies, and the corresponding prior authorization forms, are posted the Access to Care section of the Medicare Advantage Provider Manual. Our Stride (HMO) Medicare Advantage webpage also includes any necessary prior authorization forms.

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.

In addition to these prior authorization policies, Harvard Pilgrim is enacting a notification policy. Beginning January 1, 2017, notification is required for inpatient observational stays within 48 hours of admission (or if that lands on a non-business day then the next business day). Notification can be made via fax: 617-509-1159.

New Clinical Medical Policies

Also taking effect for dates of service beginning January 1, 2017, Harvard Pilgrim has developed several new medical policies to clarify coverage. Prior authorizations are not required. These clinical medical policies include:

  • Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures — This medical policy provides details on the conditions for which Harvard Pilgrim Stride (HMO) Medicare Advantage considers MAC for upper or lower gastrointestinal (GI) endoscopy medically necessary and provides coverage.
  • Vitamin B12 Assay Testing — Harvard Pilgrim’s Stride (HMO) Medicare Advantage covers Vitamin B12 Assay Testing for eligible members who are symptomatic or at risk for certain conditions.
  • Vitamin D Assay Testing — Harvard Pilgrim’s Stride (HMO)Medicare Advantage covers Vitamin D Assay Testing for eligible members who are symptomatic or at risk for Vitamin D deficiency.

For more information on Stride (HMO) Medicare Advantage plan, please visit our provider website.

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