Prior Authorization for Care

Prior authorization is a process that requires either your provider or you to obtain approval from Harvard Pilgrim before receiving specific items and services. 

Specific benefits may vary by product and/or employer group. Please reference the appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Who is responsible for obtaining prior authorizations?

  • If you have an HMO, PPO or POS plan and see an in-network provider (doctor or clinician) within your plan’s network, the provider is responsible for obtaining prior authorization for select services noted below.
  • If you have a PPO or POS product and your provider is out-of-network for your plan, your provider or you are responsible for obtaining prior authorization.

To obtain prior authorization your provider or you should call (800) 708-4414.

All requests for prior authorization are processed and a determination is rendered and communicated within two business days of receipt of all necessary information. If additional information is required, you and your provider will be notified in writing regarding the specific information needed within one business day of receipt of the request. Your provider will also be notified by phone prior to the written communication being sent.

In-network (contracted) providers are responsible for obtaining prior authorization from the plan. In the event they fail to do so, the provider is held responsible for any incurred charges with no financial liability to you, the member.

Items and services requiring prior authorizations

Under most Harvard Pilgrim plans, prior authorization is required for the following. For members enrolled in Harvard Pilgrim’s HMO products, prior authorization is required for any elective referral to a non-contracted provider.

See the criteria used to review prior authorization requests.  

  •  Admissions to Skilled Nursing Facilities and Inpatient Rehabilitation Hospitals 
  • Bariatric Surgeries 
  • Behavioral Health services including:1 
    • Non-emergent inpatient admissions
    • Alternatives to mental health and substance abuse hospitalization (i.e., Day treatment, Intensive outpatient treatment, Partial hospitalization)
    • Non-routine outpatient services including Applied Behavioral Analysis (ABA) for the treatment of autism (may not be covered under certain self-insured plans), and Transcranial Magnetic Stimulation. 
  • Breast Reduction and Reconstruction Surgeries 
  • Bronchial Thermoplasty 
  • Cholecystectomy 
  • Continuous Glucose Monitoring Systems 
  • Cosmetic/Reconstructive Surgery including: 
    • Blepharoplasty
    • Destruction of Vascular Cutaneous Lesions
    • Excision/Surgical Planing of Rhinophyma
    • Panniculectomy/Removal of Excess Tissue 
    • Ptosis repair
    • Removal of Breast Implants
    • Repair of Congenital Chest Wall Deformities
    • Rhinoplasty
    • Scar revision
    • Septoplasty
  • Dental and Oral Surgery Services performed in inpatient or SDC settings
  • Enzyme Replacement Therapy for Gaucher Disease  
  • Formulas and Enteral Nutrition 
  • Gender Reassignment Surgeries
  • Genetic Testing for Hereditary Breast and/or Ovarian Cancer
  • Gynecomastia Surgery 
  • Hip Arthroplasty/Hip Replacement2
  • Home Health Care (e.g., Visiting Nurse, Home Infusion) 
  • Hospice Services 
  • Hysterectomy
  • Immune Globulin (IVIg) 
  • Implantable Neurostimulators
  • Infertility Services including: 
    • Collection, storage and cryopreservation (freezing) of eggs, sperm, or embryos
    • Donor oocyte
    • Donor sperm 
    • Gamete intra-fallopian transfer (GIFT)
    • Intra-cytoplasmic sperm injection (ICSI)
    • Intra-Uterine Insemination (IUI) 
    • In-vitro fertilization (IVF) 
    • Embryo Transfer and Frozen embryo transfer (FET)
    • Microsurgical Epididymal Sperm Aspiration (MESA)
    • Testicular Sperm Extraction (TESE) 
    • Zygote intra-fallopian transfer (ZIFT)
  • Interventional Pain Management for Back Pain including:2
    • Epidural Injections
    • Facet Joint Injections
    • Facet Neurolysis
  • Intravenous Antibiotics for Treatment of Lyme Disease/Tick-Borne Diseases 
  • Knee Arthroplasty/Knee Replacement2
  • Non-Emergent Medical Transportation 
  • Outpatient Diagnostic Imaging Services including:2
    • Computerized Tomography and Computerized Tomography Angiography (CT/CTA)
    • Magnetic Resonance Imaging and Magnetic Resonance Angiography (MRI/MRA)
    • Nuclear Cardiology
    • Positron Emission Tomography (PET) 
    • Diagnostic CT Colonoscopy (Virtual Colonoscopy, CT Colonography)
  • Outpatient Pulmonary Rehabilitation
  • Outpatient Speech/Language Therapy (MA only) 
    • Physical and/or Occupational Therapy services require prior authorization if services are expected to exceed the member’s benefit limit. 
  • Out-of-Network Referrals 
  • Prosthetic Devices for Upper and Lower Limbs
  • Pre-Implantation Genetic Testing (PGT)
  • Selected Medical Benefit drugs and biologicals including:3
    • Abraxane (paclitaxel protein-bound)
    • Actemra (tocilizumab)
    • Acthar HP (repository corticotropin injection)
    • Adagen (pegademase bovine)
    • Adcetris (brentuximab vedotin)
    • Advate (factor VIII (antihemophilic factor, recombinant)
    • Adynovate (factor VIII (antihemophilic factor, recombinant)
    • Afstyla (factor VIII (antihemophilic factor, recombinant)
    • Aldurazyme (laronidase)
    • Alimta (pemetrexed)
    • Aloxi (palonosetron HCI)
    • Alphanate/VWF Complex/Human (factor VIII [antihemophilic factor, recombinant])
    • AlphaNine SD (factor IX (antihemophilic factor, purified, non-recombinant)
    • Alprolix (factor IX (antihemophilic factor, recombinant)
    • Anzemet (dolasetron mesylate)
    • Aralast NP (alpha-1 proteinase inhibitor)
    • Aranesp (darbepoetin alfa)
    • Arzerra (ofatumumab)
    • Avastin (bevacizumab)
    • Aveed (testosterone undecanoate)
    • Azacitidine (azacitidine)
    • Bavencio (avelumab)
    • Bebulin (factor IX, complex)
    • Beleodaq (belinostat)
    • Bendeka (bendamustine HCI)
    • BeneFIX (factor IX (antihemophilic factor, recombinant)
    • Benlysta (belimumab)
    • Berinert (c-1 esterase inhibitor [human])
    • Bivigam (immune globulin)
    • Blincyto (blinatumomab)
    • Botox (onabotulinumtoxina)
    • Carimune NF (immune globulin)
    • Cerezyme (imiglucerase)
    • Cinryze (c-1 esterase inhibitor [human])
    • Cimzia (certolizumab)
    • Cyramza (ramucirumab)
    • Dacogen (decitabine)
    • Darzalex (daratumumab)
    • Decitabine (decitabine)
    • Deferoxamine Mesylate (deferoxamine mesylate)
    • Desferal (deferoxamine mesylate)
    • Docefrez (docetaxel)
    • Docetaxel (docetaxel)
    • Doxil (doxorubicin hydrochloride, liposomal)
    • DOXOrubicin HCl Liposomal (doxorubicin hydrochloride, liposomal)
    • Dysport (abobotulinumtoxina)
    • Elaprase (idursulfase)
    • Elelyso (taliglucerace alfa)
    • Eligard (leuprolide acetate (for depot suspension)
    • Eloctate (factor VIII (antihemophilic factor, recombinant)
    • Eloxatin (oxaliplatin)
    • Emend (fosaprepitant)
    • Empliciti (elotuzumab)
    • Entyvio (vedolizumab)
    • Epogen (epoetin alfa)
    • Epoprostenol Sodium (epoprostenol)
    • Erbitux (cetuximab)
    • Erwinaze (asparaginase)
    • Euflexxa (1% sodium hyaluronate)
    • Eteplirsen (Exondys 51™ Injection)
    • Eylea (aflibercept)
    • Fabrazyme (agalsidase beta)
    • Factor IX NOC (factor IX (antihemophilic factor, recombinant)
    • Feiba (anti-inhibitor coagulant complex)
    • Firmagon (degarelix)
    • Flebogamma DIF (immune globulin)
    • Flolan (epoprostenol)
    • Folotyn (pralatrexate)
    • Fusilev (levoleucovorin calcium)
    • GamaSTAN S/D (gamma globulin)
    • Gammagard (immune globulin)
    • Gammaked (immune globulin)
    • Gammaplex (immune globulin)
    • Gamunex-C (immune globulin)
    • Gazyva (obinutuzumab)
    • Gemcitabine HCl (gemcitabine hydrochloride)
    • Gemzar (gemcitabine hydrochloride)
    • Genvisc 850 (hyaluronan or derivative)
    • Glassia (alpha-1 proteinase inhibitor)
    • Granix (tbo-filgrastim)
    • Halaven (eribulin mesylate)
    • Helixate FS (factor VIII (antihemophilic factor, recombinant)
    • Hemofil M (factor VIII (antihemophilic factor, recombinant)
    • Herceptin (trastuzumab)
    • Hizentra (immune globulin)
    • Humate-P (factor VIII (antihemophilic factor, recombinant)
    • Hyalgan (hyaluronan or derivative)
    • Hyqvia (immune globulin infusion 10% [human] recombinant human hyaluronidase)
    • Ilaris (canakinumab)
    • Inflectra (infliximab)
    • Istodax (romidepsin)
    • Ixempra Kit (ixabepilone)
    • Ixinity (factor IX [antihemophilic factor, recombinan])
    • Jevtana (cabazitaxel)
    • Kadcyla (ado-trastuzumab emtansine)
    • Kalbitor (ecallantide)
    • Kanuma (sebelipase alfa)
    • Keytruda (pembrolizumab)
    • Koate-DVI (factor VIII [antihemophilic factor, recombinant])
    • Kogenate FS/Kogenate FS Bio-Set (factor VIII [antihemophilic factor, recombinant])
    • Kovaltry (factor VIII [antihemophilic factor, recombinant])
    • Krystexxa (pegloticase)
    • Kyprolis (carfilzomib)
    • Lemtrada (alemtuzumab)
    • Leukine (sargramostim [gm-csf])
    • Levoleucovorin Calcium (levoleucovorin calcium)
    • Lucentis (ranibizumab)
    • Lumizyme (alglucosidase alfa)
    • Lupron Depot (leuprolide acetate)
    • Lupron Depot - PED (leuprolide acetate)
    • Lupron Depot - Prostate Cancer (leuprolide acetate)
    • Makena (hydroxyprogesterone caproate)
    • Mircera (epoetin beta/methoxy polyethylene glycol)
    • Mitoxantrone HCl (mitoxantrone hydrochloride)
    • Monoclate-P (factor VIII [antihemophilic factor, recombinant])
    • Mononine (factor IX (antihemophilic factor, purified, non-recombinant)
    • Monovisc (hyaluronan or derivative)
    • Mozobil (plerixafor injection)
    • Myobloc (rimabotulinumtoxinb)
    • Naglazyme (galsulfase)
    • Neulasta/Neulasta Onpro (pegfilgrastim)
    • Neupogen (filgrastim)
    • Novoeight (factor VIII [antihemophilic factor, recombinant])
    • NovoSeven RT (factor VIIa [antihemophilic factor, recombinan])
    • Nplate (romiplostim)
    • Nucala (mepolizumab)
    • Nuwiq (factor VIII [antihemophilic factor, recombinant])
    • Obizur (factor VIII [antihemophilic factor, recombinant])
    • Ocrevus (ocrelizumab)
    • Octagam (immune globulin)
    • Octreotide Acetate (octreotide, non-depot form for subcutaneous or intravenous injection)
    • Oncaspar (pegaspargase)
    • Opdivo (nivolumab)
    • Orencia/Orencia Clickject (abatacept)
    • Orthovisc (hyaluronan or derivative)
    • Oxaliplatin (oxaliplatin)
    • Perjeta (pertuzumab)
    • Portrazza (necitumumab)
    • Privigen (immune globulin)
    • Procrit (epoetin alfa)
    • Profilnine/Profilnine SD (factor IX, complex)
    • Prolastin-C (alpha-1 proteinase inhibitor)
    • Proleukin (aldesleukin)
    • Prolia (denosumab)
    • Radicava (edaravone)
    • Reclast (zoledronic acid)
    • Recombinate (factor VIII [antihemophilic factor, recombinant])
    • Remicade (infliximab)
    • Remodulin (treprostinil)
    • Rituxan - Oncology (rituximab)
    • Rituxan - RA (rituximab)
    • Rixubis (factor IX [antihemophilic factor, recombinant])
    • Ruconest (c1 esterase inhibitor [recombinant])
    • Sandostatin (octreotide)
    • Sandostatin LAR Depot (octreotide depot)
    • Signifor LAR (pasireotide)
    • Simponi Aria (golimumab)
    • Soliris (eculizumab)
    • Somatuline Depot (lanreotide)
    • Spinraza (nusinersen)
    • Stelara (ustekinumab)
    • Supartz/Supartz FX (hyaluronan or derivative)
    • Supprelin LA (histrelin acetate)
    • Sylvant (siltuximab)
    • Synagis (palivizumab)
    • Synribo (omacetaxine mepesuccinate)
    • Synvisc/Synvisc One (hylan G-F 20)
    • Taxotere (docetaxel)
    • Temodar (temozolomide)
    • Torisel (temsirolimus)
    • Treanda (bendamustine HCI)
    • Trelstar/Terlstar Mixject (triptorelin pamoate)
    • Tysabri (natalizumab)
    • Vantas (histrelin acetate)
    • Vectibix (panitumumab)
    • Velcade (bortezomib)
    • Veletri (epoprostenol)
    • Vidaza (azacitidine)
    • Vimizim (elosulfase alfa)
    • Vpriv (velaglucerase alfa)
    • Wilate (von Willebrand factor complex [human])
    • Xeomin (incobotulinumtoxinA)
    • Xgeva (denosumab)
    • Xolair (omalizumab)
    • Xyntha/Xyntha Solofuse (factor VIII [antihemophilic factor, recombinant])
    • Yervoy (ipilimumab)
    • Zaltrap (ziv-aflibercept)
    • Zarxio (filgrastim-sndz)
    • Zemaira (alpha-1 proteinase inhibitor)
    • Zoladex (goserelin acetate)
    • Zoledronic Acid (zoledronic acid)
    • Zometa (zoledronic acid)
  • Shoulder Arthroscopy2
  • Sinus Surgeries
  • Sleep Diagnostics including:2
    • Home or Attended Sleep Studies
  • Spine Surgeries including:2
    • Artificial Cervical Disc 
    • Lumbar Decompression
    • Lumbar Fusion (Single and Multiple Level)
    • Lumbar Microdiscectomy
  • Surgical Treatment of Obstructive Sleep Apnea (MMO or UPPP)
  • Temporomandibular Joint Disorders
  • Transcranial Magnetic Stimulation
  • Treatment of Varicose Veins 
  • Urinary Incontinence Surgeries
  • New Technologies that have not been assessed and incorporated into Harvard Pilgrim benefits
     

Contracted vendors for prior authorizations

For certain services, prior authorization review is delegated to contracted vendors. Harvard Pilgrim retains oversight and overall accountability for all delegated services.

TABLE CAPTION
  Type of service Contracted Vendor Contact Information
3 Selected Medical Benefit drugs and biologicals CVS Health-NovoLogix

Call CVS Health-NovoLogix at (844) 387‐1435

 

Questions about Harvard Pilgrim’s prior authorization process?

Call Member Services at (888) 888-4742. For TTY service, call 711.

Initial inquiries are referred to Member Services for review and response where appropriate. Routine inquiries regarding specific cases are triaged by Member Services and referred to appropriate Utilization Management (UM) staff via voice mail. UM Staff are available Monday - Friday, 8:30 a.m. – 5 p.m. Inquiries received outside normal business hours are recorded on voice mail and returned within one business day of receipt.