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StrideSM (HMO) Medicare Advantage Prior Authorization and Referral Chart


Stride (HMO) Medicare Advantage Prior Authorization/Referral Chart

Service Category

Authorization/Referral Rules & Forms

Bariatric Surgery

Authorization required. See Bariatric Surgeries Prior Authorization Request Form.

Breast Surgery

Authorization required. See Breast Surgery Prior Authorization Request Form.

Cardiac Rehabilitation Services 

Referral required.

Chiropractic Services 

Referral required.

Cholecystectomy (Eff. through 12.31.17)
Cholecystectomy (Eff. beginning 1.1.18)

Authorization required. See Cholecystectomy Prior Authorization Request Form.

Continuous Glucose Monitoring Systems

Authorization required. See DME Prior Authorization Request Form (Eff. through 12.31.17). DME Prior Authorization Request Form (Eff. beginning 1.1.18).

Drugs, Medicare Part B Rx, and home infusion drugs including:

Prior authorization required for listed drugs:

Durable Medical Equipment (DME) (Eff. through 12.31.17
Durable Medical Equipment (DME) (Eff. beginning 1.1.18) 

Prior authorization is required.

End Stage Renal Disease (ESRD) 

Referral required.

Eye Exams 

Referral required except for annual eye exam.

Extended Care Facility

Authorization required. See Extended Care Facility Fax Request Form.

Gastrointestinal Endoscopy — Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedure 

Authorization required. See Prior Authorization Request Form.

Hearing Exams 

Referral required.

Hip Surgery

Prior Authorization required. See Hip/Knee/Shoulder Surgeries (HKSS) prior authorization policy. (Eff. beginning 1.1.18)

Home Health Services

Authorization required. Please complete the Universal Home Health Services Prior Authorization Form and fax it to 866-874-0857.

Home Infusion

Authorization required. See Prior Authorization Request Form.

Hysterectomy

Authorization required. See Hysterectomy Prior Authorization Request Form.

Implantable Neurostimulators

Authorization required. See Implantable Neurostimulators Prior Authorization Request Form.

Inpatient Hospital — Acute Medical 

Prior authorization required for elective (non-urgent/emergent) admissions. See Prior Authorization Request Form. Notification required for urgent/emergent admissions (within 48 hours of admission).

Inpatient Hospital — Mental Health 

Prior authorization required for elective admissions.
See Prior Authorization Request Form.
Notification required for urgent/emergent admissions
(see Behavioral Health Authorization and Notification policy).

Inpatient services covered during a non-covered inpatient stay 

Authorization required. See Prior Authorization Request Form.

Kidney Disease Education Services 

Referral required.

Medical Nutrition Therapy 

Referral required.

Knee Surgery

Prior Authorization required. See Hip/Knee/Shoulder Surgeries (HKSS) prior authorization policy. (Eff. beginning 1.1.18)

Medical Transportation 

Authorization required for all non-emergent air (fixed wing) and ground transportation. See Transportation Prior Authorization Request Form.

Molecular Diagnostic Management (Eff. beginning 1.1.18)

Prior Authorization required. Molecular Diagnostic Management Authorization Policy. (Eff. beginning 1.1.18)

Non-routine Outpatient Mental Health 

Authorization required (see Behavioral Health Authorization and Notification policy).

Non-routine Outpatient Substance Abuse Services 

Authorization required (see Behavioral Health Authorization and Notification policy).

Non-routine Partial Hospitalization Substance Abuse Services 

Authorization required (see Behavioral Health Authorization and Notification policy).

Inpatient Hospital - Observation Stays 

Notification required for observational stays (within 48 hours of admission or the next business day).

Outpatient Advanced Imaging 

Authorization required (see Outpatient Advanced Imaging Authorization).

Outpatient Physical & Occupational Therapy Services

Authorization required. See Outpatient Physical & Occupational Therapy Services Prior Authorization Request Form.

Podiatry services 

Referral required.
Prosthetics/medical Supplies Authorization required for any single item with an allowable payment amount of $500 or more.
See Prior Authorization Request Form.

Provider specialist services excluding psychiatric services 

Referral required.

Pulmonary Rehabilitation Services 

Referral required.

Reconstructive and Restorative Skin Surgeries:  

Authorization required. See Prior Authorization Request Form.

Authorization required. See Reconstructive & Restorative Skin Services Prior Request Form.

Reduction Mammoplasty (Eff. through 12.31.17)
Reduction Mammoplasty (Eff. beginning 1.1.18)

Authorization required. See Breast Surgery Prior Authorization Request Form.

Shoulder Surgery

Prior Authorization required. See Hip/Knee/Shoulder Surgeries (HKSS) prior authorization policy. (Eff. beginning 1.1.18)

Sinus Surgeries (Eff. through 12.31.17)
Sinus Surgeries (Eff. beginning 1.1.18)

Authorization required. See Sinus Surgeries Prior Authorization Request Form.

Speech therapy services- outpatient 

Referral required.

Sleep Studies

Prior Authorization required. See Sleep Studies prior authorization policy. (Eff. beginning 1.1.18)

Spine Management and Prior Authorization 

Authorization required (see Spine Management and Prior Authorization).

Temporomandibular Joint (TMJ) Surgeries

Authorization required. See Prior Authorization Request Form.

Total Ankle Replacement 

Authorization required. See Total Ankle Replacement Prior Authorization Request Form.

Total Hip Replacement 

Authorization required. See Total Hip Replacement Prior Authorization Request Form.

Total Knee Arthroplasty

Authorization required. See Total Knee Arthroplasty Prior Authorization Request Form.

Gender Reassignment Services (Eff. through 12.31.17)
Transgender Health Services (Eff. 1.1.18)

Prior Authorization required.

Urinary Incontinence Surgeries 

Authorization required. See Urinary Incontinence Surgeries Prior Authorization Request Form.

Varicose Vein 

Authorization required for certain interventional treatments for varicose veins. See Prior Authorization Request Form.


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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

Claim Review Form

Claims Appeal Form

Claim Overpayment Refund 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