As part of our continuing network engagement series, we’re offering virtual sessions on claims and appeals in June.

As part of our integration work as a combined organization, we are reviewing and assessing existing Harvard Pilgrim Health Care and Tufts Health Plan Payment Policies to maintain consistency.

Harvard Pilgrim will require prior authorization for the use of bone growth stimulators for commercial members for dates of service beginning July 1, 2021, using InterQual criteria for medical review.

Beginning on July 1, 2021, Harvard Pilgrim will offer the innovative virtually based network product SimplyVirtual HMO for employer groups in New Hampshire and Maine.

Effective beginning July 1, 2021, Harvard Pilgrim will apply industry standard frequency limits for a number of radiation oncology procedure codes, based on guidance from the American Society of Radiation and CMS.

Harvard Pilgrim maintains a commercial medical policy for prior authorization review of lower limb prostheses and prosthesis equipment. Refer to the policy for coverage criteria, coding, and exclusions.

CMS is adding additional exclusions for the Statin Use in Persons with Diabetes Star Measure for 2021, and we request your partnership in ensuring that the associated ICD-10 codes are submitted to us, as appropriate.

As a reminder, Harvard Pilgrim requires prior authorization for all single agent Tysabri (natalizumab) administered outside the inpatient setting for members of our Medicare Advantage plans.

Harvard Pilgrim maintains commercial and Medicare Advantage policies that outline network practitioner standards regarding clinician availability, timeliness of appointments, and telephone accessibility, and more.

Harvard Pilgrim would like to remind our provider network of our current coverage for epinephrine products within the commercial formularies (Premium, Value, Core NH).

Visit the COVID-19 page on our provider website to access resources designed to aid you in conducting operations during the pandemic, including updates on coding, coverage, policies, and procedures.

Harvard Pilgrim is thrilled to introduce the new Provider Training and Events page on our provider website, developed with the aim of delivering the best possible provider experience.