Prior authorization medical review criteria

Product specific

For all products, when prior authorization is required, 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.

Harvard Pilgrim’s prior authorization requirements for commercial (HMO, POS, PPO) products are different from the requirements for its Stride (HMO) Medicare Advantage product. Please choose the appropriate product below to view Harvard Pilgrim’s product-specific Medical Review Criteria.

Commercial Prior Authorization Medical Review Criteria

InterQual® Criteria

STRIDE ^SM Prior Authorization Medical Review Criteria