Please note: This page includes clinical medical criteria (both authorization and non-authorization) as well as some administrative authorization policies (which include a PM notation after the title). See below for more information on clinical medical criteria; for questions on administrative policies, contact the Provider Service Center at 1-800-708-4414. In addition to these policies, please refer to the Referral, Notification, and Authorization section of the commercial Provider Manual for our notification and referral policies.
About Our Medical Criteria
Harvard Pilgrim uses written criteria based on sound clinical evidence to evaluate the medical appropriateness of health care services. These criteria are objective and based on current clinical and medical evidence and applied with consideration of individual needs and characteristics (e.g., age, comorbidities, prior treatment and complications) and the availability of services within the local delivery system. For a hard copy of these policies, please contact the Medical Management department at 617-509-8723.