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: 
    • 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 Replacement
  • 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: (National Imaging Associates)
    • Epidural Injections
    • Facet Joint Injections
    • Facet Neurolysis
  • Intravenous Antibiotics for Treatment of Lyme Disease/Tick-Borne Diseases 
  • Knee Arthroplasty/Knee Replacement
  • Non-Emergent Medical Transportation 
  • Outpatient Diagnostic Imaging Services including: (National Imaging Associates)
    • 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: 
    • Actemra (tocilizumab) 
    • Aloxi (palonosetron HCl injection)
    • Anzemet (dolasetron mesylate)
    • Aralast NP
    • Cerezyme
    • Cimzia
    • Cinryze® (C1 esterase inhibitor- human) 
    • Elelyso
    • Emend (fosaprepitant dimeglumine)
    • Entyvio
    • Glassia
    • H.P. Acthar Gel (repository corticotrophin injection)
    • Hyaluronate Preparations for Osteoarthritis of the Knee
    • Ilaris
    • Keytruda
    • Lemtrada
    • Lumizyme
    • Myozyme
    • NPlate
    • Opdivo
    • Orencia
    • Prolastin-C
    • Prolia
    • Remicade
    • Rituxan
    • Sandostatin LAR Depot (octreotide depot) 
    • Simponi Aria
    • Soliris
    • Stelara
    • Tysabri
    • VPRIV
    • Xgeva
    • Xolair (omalizumab)
    • Yervoy (ipilimumab) 
    • Zemaira
  • Sinus Surgeries
  • Sleep Diagnostics including (National Imaging Associates)
    • Home or Attended Sleep Studies
  • Spine Surgeries including: (National Imaging Associates)
    • 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
Interventional Pain Management for Back Pain and Lumbar Spine Surgeries National Imaging Associates (NIA) Call National Imaging Associates (NIA) at (800) 642-7543
Sleep Diagnostics National Imaging Associates (NIA) Call National Imaging Associates (NIA) at (800) 642-7543
 

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.