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. Check out the comprehensive plans we have to help keep you and your family healthy. (800) 708-4414 for medical services (888) 777-4742 for mental health and substance use disorder treatment Prior authorization needed Under most Harvard Pilgrim plans, prior authorization is required for the following. Please bear with us as we work to upgrade this information to the same standards as the rest of our website. Physical and/or occupational therapy services require prior authorization if services are expected to exceed the members benefit limit. Access all the forms you need to help guide you on your health care journey with us. Open the document in the online editing tool. The specific benefits subject to prior authorization may vary by product and/or employer group. Together, we're delivering ever-better health care experiences to everyone in our diverse communities. Understanding what your plan has to offer, Prior authorization, quantity limits & step therapy policies. Thats why we offer tools that help you estimate and manage your health care costs before you receive services. Know your care options before you need them. Harvard Pilgrim Health Care . of a member, please complete and submit the Personal Representative Cover Form with your legal documentation in order to be documented in Harvard Pilgrims system. We are sorry. Production Coordinator. Production Coordinator. Commercial Prior Authorization Medical Review Criteria, STRIDE SM Prior Authorization Medical Review Criteria. Destruction of vascular cutaneous lesions, Repair of congenital chest wall deformities, Dental or oral surgery services performed in inpatient or SDC settings, Lumbar fusion (single and multiple level), Surgical treatment of obstructive sleep apnea (MMO or UPPP), New technologies not assessed and incorporated into Harvard Pilgrim benefits, Physical and/or occupational therapy services, Interventional pain management for back pain, Selected medical benefit drugs and biologicals, Genetic testing for hereditary breast and/or ovarian cancer. From the most commonly asked questions to understanding your plan, our Help section provides everything you need to know to successfully navigate your health care journey. Harvard Pilgrim will require prior authorization for orthognathic surgery for Commercial members, effective for dates of service beginning Oct. 1, 2022, and the following InterQual criteria subsets will be used for medical review: Bone Augmentation, Mandible Bone Augmentation, Maxilla Osteotomy, Anterior Segment, Mandible Osteotomy, LeFort I Try to update your search criteria. . This form allows you to authorize Harvard Pilgrim to release/disclose certain protected health information (PHI), according to the terms you specify. Routine inquiries regarding specific cases are triaged by Member Services and referred to appropriate Utilization Management (UM) staff via voicemail. Understanding what your plan has to offer, Prior authorization, quantity limits & step therapy policies. Being a Harvard Pilgrim member is so rewarding! Practicing mindfulness involves breathing methods, guided imagery and more to help the mind to refocus on the present moment, relax the body and mind, and reduce stress. Chemotherapy/Cancer Treatment Medication Chemotherapy Support Drugs Pediatric/Adult Formula Plan for a healthy future today! Save big with exclusive discounts on a wide variety of health and well-being products and services. Look up drugs, get prices, find pharmacies and more. No results found for #SEARCH_KEYWORD# your search . Harvard Pilgrim's prior authorization requirements for commercial (HMO, POS, PPO) products are different from the requirements for its Stride (HMO) Medicare Advantage product. Here you'll find information on a variety of health topics: behavioral health conditions, healthy tips for any age, managing chronic pain and choosing your primary care provider. Please choose the appropriate product below to view Harvard Pilgrim's product-specific Medical Review Criteria. Learn how! You may need assistance from your provider to complete this form. To claim reimbursement for travel expenses that are primarilly for and essential to covered services that are restricted or prohibited in your state of residence as a result of state law, youll want to fill out the Travel Benefit Reimbursement form. As of Jan. 1, 2020, Harvard Pilgrim began utilizing OptumRx as our pharmacy benefit manager. Here you can submit batch claim files, verify patient eligibility, send/receive specialty referrals, submit authorization requests, and more. From personalized support in dealing with stressful health conditions or life changes to behavioral health tools, we make it easy to talk (or message!) Did you know you can get reimbursed for fees paid toward fitness facilities, certain complementary and alternative medicine services, weight management programs and more? Youll want to fill out the Member authorization to release PHI form (pdf). Set and achieve your personal health goals with one-on-one support from our personal health coaches. Prior authorization required for Amvuttra (HCPCS code J3490), a new-to-market biosimilar of Onpattro used to treat polyneuropathy of . (Have your ID card handy.). Let us simplify the process! To coordinate medical or dental benefits for members covered by another health, dental or Medicare insurance plan, youll want to completethe Coordination of Benefits questionnaire. Please choose the appropriate product below to view Harvard Pilgrims product-specific Medical Review Criteria. An Activity Summary shows what we paid and what you owe your providers for medical care you received. Together, we're delivering ever-better health care experiences to everyone in our diverse communities. LOGIN or REGISTER Key Contacts Provider Service Center (commercial): 800-708-4414 Referral and Authorization Requests: 800-708-4414 Care Management 888-888-4742, x 31035 E-Services/EDI-Direct: Plan for a healthy future today! There are three variants; a typed, drawn or uploaded signature. Policies, Clinical Coverage Criteria and Request Forms, Network Operations & Care Delivery Management, Medical Drug Dosage and Frequency Exception Criteria Expanded, Prescription Infant Formula Coverage Update, Rate Increase for Early Intervention Providers, Reduced Payment for Late Notification of Inpatient Admissions, Help Us Keep Directory Information Up to Date, Medical Policy for Routine Costs Associated with Clinical Trials, 2022 Home Care Seasonal Flu Vaccine Fee Schedule, Reminder: Medicare Part B Step Therapy Policy, Enjaymo to be Covered With Prior Authorization, Prior Authorization for Solid Organ Transplants, Documented diagnosis of primary cold agglutinin disease, Prescribed by, or in consultation with, a hematologist, Documented history of at least one blood transfusion in the previous six months before the initiation of treatment with Enjaymo. Please bear with us as we work to upgrade this information to the same standards as the rest of our website. Read the recommendations to find out which data you need to provide. UM staff are available Monday-Friday, 8:30 a.m. - 5 p.m. ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. If you are the Personal Representative (e.g., health care proxy, power of attorney, etc.) Whether you need help managing your weight or controlling your blood pressure, a health coach will support, educate and motivate you to achieve your health goals. We get it health care can be confusing. Specific items and services require that either your provider or you obtain approval (prior authorization) from Harvard Pilgrim. Managing out-of-pocket costs can be confusing. Managing out-of-pocket costs can be confusing. Senior Manager, Provider Communications, Kristin Edmonston, Specific items and services require that either your provider or you obtain approval (prior authorization) from Harvard Pilgrim. To ensure that a claim for an injury or illness resulting from an accident, such as a slip and fall, is processed correctly, simply complete the Insurance, Liability and Recovery questionnaire. Save more on products and services you love just for being a member. New to Medicare, or retiring? Coverage of the purchase of a UVB home phototherapy unit may be authorized when the member has a diagnosis of moderate-to-severe psoriasis and a history of frequent psoriasis flares that require home therapy for suppression, or when the member has a diagnosis of severe atopic dermatitis/eczema, has failed first line therapies, and meets all the criteria on the policy specific to that indication. 2022 Harvard Pilgrim Health Care, Inc. All rights reserved. Check out the comprehensive plans we have to help keep you and your family healthy. To claim reimbursement for qualifying childbirth classes covered under your plan, youll want to fill out theChildbirth Class Reimbursement form (pdf). Outpatient diagnostic imaging services, including: Computerized tomography and computerized tomography angiography (CT/CTA), Magnetic resonance imaging and magnetic resonance angiography (MRI/MRA), Diagnostic CT colonoscopy (virtual colonoscopy, CT colonography), For hereditary breast and/or ovarian cancer, Collection, storage and cryopreservation (freezing) of eggs, sperm or embryos, Embryo transfer and frozen embryo transfer (FET), Microsurgical epididymal sperm aspiration (MESA), Intravenous antibiotics for treatment of Lyme disease/tick-borne diseases, Acthar HP (repository corticotropin injection), Advate (factor VIII (antihemophilic factor, recombinant), Adynovate (factor VIII (antihemophilic factor, recombinant), Afstyla (factor VIII (antihemophilic factor, recombinant), Alphanate/VWF Complex/Human (factor VIII [antihemophilic factor, recombinant]), AlphaNine SD (factor IX (antihemophilic factor, purified, non-recombinant), Alprolix (factor IX (antihemophilic factor, recombinant), Aralast NP (alpha-1 proteinase inhibitor), BeneFIX (factor IX (antihemophilic factor, recombinant), Berinert (c-1 esterase inhibitor [human]), Deferoxamine Mesylate (deferoxamine mesylate), Doxil (doxorubicin hydrochloride, liposomal), DOXOrubicin HCl Liposomal (doxorubicin hydrochloride, liposomal), Eligard (leuprolide acetate (for depot suspension), Eloctate (factor VIII (antihemophilic factor, recombinant), Factor IX NOC (factor IX (antihemophilic factor, recombinant), Gemcitabine HCl (gemcitabine hydrochloride), Helixate FS (factor VIII (antihemophilic factor, recombinant), Hemofil M (factor VIII (antihemophilic factor, recombinant), Humate-P (factor VIII (antihemophilic factor, recombinant), Hyqvia (immune globulin infusion 10% [human] recombinant human hyaluronidase), Ixinity (factor IX [antihemophilic factor, recombinan]), Koate-DVI (factor VIII [antihemophilic factor, recombinant]), Kogenate FS/Kogenate FS Bio-Set (factor VIII [antihemophilic factor, recombinant]), Kovaltry (factor VIII [antihemophilic factor, recombinant]), Levoleucovorin Calcium (levoleucovorin calcium), Lupron Depot - Prostate Cancer (leuprolide acetate), 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), Novoeight (factor VIII [antihemophilic factor, recombinant]), NovoSeven RT (factor VIIa [antihemophilic factor, recombinan]), Nuwiq (factor VIII [antihemophilic factor, recombinant]), Obizur (factor VIII [antihemophilic factor, recombinant]), Octreotide Acetate (octreotide, non-depot form for subcutaneous or intravenous injection), Profilnine/Profilnine SD (factor IX, complex), Prolastin-C (alpha-1 proteinase inhibitor), Recombinate (factor VIII [antihemophilic factor, recombinant]), Rixubis (factor IX [antihemophilic factor, recombinant]), Ruconest (c1 esterase inhibitor [recombinant]), Supartz/Supartz FX (hyaluronan or derivative), Trelstar/Terlstar Mixject (triptorelin pamoate), Wilate (von Willebrand factor complex [human]), Xyntha/Xyntha Solofuse (factor VIII [antihemophilic factor, recombinant]), Prosthetic devices for upper and lower limbs. with a behavioral health professional. Prior authorization is a process that requires either your provider or you to obtain approval from Harvard Pilgrim before receiving specific items and services. Reimbursement forms, authorization forms, vision care claim forms, tax forms, plan documents and more all in one convenient location. Check out your options and take control of your health care needs today. Thats why we offer tools that help you estimate and manage your health care costs before you receive services. Check out your options and take control of your health care needs today. To claim reimbursement for an approved health club or fitness facility membership that you have paid for out of pocket, youll want to fill out the Fitness Reimbursement form. Prior authorization for Enjaymo a classical complement inhibitor indicated to decrease the need for red blood cell transfusion due to hemolysis in adults with cold agglutinin disease may be granted when the following criteria are met: To request authorization, please contact CVS HealthNovoLogix via phone (844-387-1435) or fax (844-851-0882). Specific items and services require that either your provider or you obtain approval (prior authorization) from Harvard Pilgrim. Understanding what your plan has to offer, Prior authorization, quantity limits & step therapy policies, Member authorization to release PHI form (pdf), Confidential Exchange of Information form (pdf), Disabled Adult Dependent Verification form (pdf), Childbirth Class Reimbursement form (pdf), Prescription Drug Reimbursement Claim form (pdf). Save more on products and services you love just for being a member. Effective for dates of service beginning June 20, 2022, Harvard Pilgrim will cover the medication Enjaymo (HCPCS code J3490), with prior authorization, for members of our Commercial plans. Harvard Pilgrims prior authorization requirements for commercial (HMO, POS, PPO) products are different from the requirements for itsStride (HMO) Medicare Advantage product. Check out the comprehensive plans we have to help keep you and your family healthy. 2022Harvard Pilgrim Health Care, Inc. All rights reserved. To request authorization, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). (Have your ID card handy.). Learn more about the prior authorization process in this section. Let us guide you toward information on how to apply for Social Security benefits, what types of health care options are available to you under Medicare, and much more. Inquiries received outside normal business hours are recorded on voicemail and returned within one business day of receipt. Harvard Pilgrim will require prior authorization for UVB home units for skin disease, effective for dates of service beginning Nov. 1, 2022, for members of our Commercial plans. To allow Harvard Pilgrim representatives to speak to a parent about the health coverage and care of their dependent (under age 18) when parent is not listed on that minors policy, aStatement of Parental Rights form (pdf) will need to be completed. The information you are about to access may not meet accessibility standards for people with disabilities, including visual impairment, nor is it optimized for people using tablets or phones. Reimbursement forms, authorization forms, vision care claim forms, tax forms, plan documents and more all in one convenient location. Know your care options before you need them. Look up drugs, get prices, find pharmacies and more. An Activity Summary shows what we paid and what you owe your providers for medical care you received. Know your options and select the right care for your specific needs, day or night, virtually or in-person. To claim reimbursement for medical and hospital services covered under your plan that you have paid for out of pocket, youll want to fill out the Medical Reimbursement form. Access all the Medicare Advantage Stride forms you need enrollment, reimbursement, prescription drug, billing, representative designation, privacy and more. Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. Audrey Kleinberg, Harvard Pilgrim manages our own drug formularies, the development of utilization management criteria, and appeals. Practicing mindfulness involves breathing methods, guided imagery and more to help the mind to refocus on the present moment, relax the body and mind, and reduce stress. The information you are about to access may not meet accessibility standards for people with disabilities, including visual impairment, nor is it optimized for people using tablets or phones. From the most commonly asked questions to understanding your plan, our Help section provides everything you need to know to successfully navigate your health care journey. We make staying healthy fun, informative and engaging with a variety of activities on topics like eating healthy, mindfulness, financial wellness, stress management and more! Here you'll find information on a variety of health topics: behavioral health conditions, healthy tips for any age, managing chronic pain and choosing your primary care provider. Coverage Policies are developed to assist in administering health benefits and aid in the determination of medically necessary therapy. Thats why we have a Care Team of registered nurses, clinical social workers and certified health coaches on hand to help answer your questions. New to Medicare, or retiring? From preparing for maternity leave to dealing with being a working parent, find resources to support you no matter where you are in the journey of reproductive health, pregnancy and parenthood. Did you know you can get reimbursed for fees paid toward fitness facilities, certain complementary and alternative medicine services, weight management programs and more? Authorization forms To release or disclose information among designated individuals. Were here to provide education and information about your medicines, including potential side effects, helpful tips on how to take your medications and more. Decide on what kind of signature to create. Know your options and select the right care for your specific needs, day or night, virtually or in-person. To claim reimbursement for your childs covered dental care received outside the dental network, youll want to fill out the Pediatric Dental Claim form (pdf). From personalized support in dealing with stressful health conditions or life changes to behavioral health tools, we make it easy to talk (or message!) We get it health care can be confusing. Weve developed a medical policy for the management of these authorizations, which outlines Harvard Pilgrims clinical coverage criteria and exclusions. From personalized support in dealing with stressful health conditions or life changes to behavioral health tools, we make it easy to talk (or message!) Youll want to fill out the Confidential Exchange of Information form (pdf). Harvard Pilgrim Prior Authorization Policies OncoHealth conducts medical necessity and utilization review for certain oncology medical drugs and radiotherapy codes on behalf of Harvard Pilgrim Health Care. An Activity Summary shows what we paid and what you owe your providers for medical care you received. Commercial Clinical/Authorization Policies, Medical Benefit Drugs: Medical Necessity Guidelines, About Our StrideSM (HMO)/(HMO-POS) Medicare Advantage Plans, Medicare Advantage Clinical/Auth. Commercial Prior Authorization Medical Review Criteria Outpatient diagnostic imaging services including: Computerized tomography and computerized tomography Angiography (CT/CTA), Outpatient speech/language therapy (MA only). Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. The following HCPCS codes related to UVB home units will require prior authorization: For complete information, please refer to Harvard Pilgrims UVB Home Units for Skin Disease Medical Policy. Plan for a healthy future today! To obtain a prior authorization, you or your provider should call . Download a Standard Prior Authorization Request form If your patient's plan requires Prior Authorization for a service or procedure listed below, please complete the Standard Prior Authorization Requestform in addition to the applicable form below. Learn how! Practicing mindfulness involves breathing methods, guided imagery and more to help the mind to refocus on the present moment, relax the body and mind, and reduce stress. In order to verify your dependents eligibility as a disabled adult which includes authorization to obtain protected health information youll need to fill out the Disabled Adult Dependent Verification form (pdf). with a behavioral health professional. See the criteria used to review prior authorization requests, Selected medical benefit drugs and biologicals including:1. For HMO, POS and PPO plans, to claim reimbursement for prescription medications covered under your plan that you have paid for out of pocket, youll want to complete the Prescription Drug Reimbursement Claim form (pdf). From preparing for maternity leave to dealing with being a working parent, find resources to support you no matter where you are in the journey of reproductive health, pregnancy and parenthood. Set and achieve your personal health goals with one-on-one support from our personal health coaches. Discover which Medicare plan is right for you. Know your options and select the right care for your specific needs, day or night, virtually or in-person. Save more on products and services you love just for being a member. No prior authorization from Harvard Pilgrim is needed to receive care Coverage for preventative services such as physicals and routine eye exams, as well as necessary services and emergency care Built-In discount and saving programs for products & services such nutrition/weight management, eyewear, and medicine services Being a Harvard Pilgrim member is so rewarding! ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Let us simplify the process! Thats why we offer tools that help you estimate and manage your health care costs before you receive services. Authorize Harvard Pilgrim to release/disclose your health information Authorize behavioral health practitioners to release your health information Authorize someone to act as your health care representative Create your signature and click Ok. Know your care options before you need them. Look up drugs, get prices, find pharmacies and more. Learn more about the prior authorization process in this section. These standard forms can be used across payers and health benefit managers. Choose My Signature. Senior Manager, Provider Communications, Kristin Edmonston, Director, Provider Relations & Communications, Annmarie Dadoly, For payer specific policies, please reference the payer specific websites. Let us simplify the process! Discover which Medicare plan is right for you. Were here to provide education and information about your medicines, including potential side effects, helpful tips on how to take your medications and more. Access all the Medicare Supplement Plan forms you need additional health insurance coverage, accident/injury questionnaire, authorizations, reimbursement, claim, representative designation and more. For complete information, including coverage criteria and FDA-approved maximum dosage and frequency limits, refer to Harvard Pilgrim's Commercial Enjaymo Medical Policy. From the most commonly asked questions to understanding your plan, our Help section provides everything you need to know to successfully navigate your health care journey. Learn more about the prior authorization process in this section. Together, we're delivering ever-better health care experiences to everyone in our diverse communities. Massachusetts Medication Request form (MA providers only) (pdf), New Hampshire Harvard Pilgrim standard form (for all other providers) (pdf), Harvard Pilgrim standard form (for all other providers) (pdf). Audrey Kleinberg, Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. 2022 Harvard Pilgrim Health Care, Inc. All rights reserved. Prior Authorization A standardized, or "uniform," prior authorization (PA) form may be required in certain states to submit PA requests to a health plan for review, along with the necessary clinical documentation. Managing out-of-pocket costs can be confusing. Massachusetts Administrative Simplification Collaborative-Standardized Prior Authorization Request Form Reference Guide V1 . For prescription medications, be sure to use thePrescription Drug Reimbursement Claim form (pdf). Director, Provider Relations & Communications, Annmarie Dadoly, 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. To claim reimbursement for covered behavioral health services received out of network, youll want to fill out the Behavioral Health Claim form. We get it health care can be confusing. Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. Follow these simple guidelines to get Harvard Pilgrim Health Prior Authorization For Medication ready for submitting: Choose the sample you require in our collection of legal forms. 2022Harvard Pilgrim Health Care, Inc. All rights reserved. 1Must get prior authorization from Harvard Pilgrims list of contracted vendors. Were here to provide education and information about your medicines, including potential side effects, helpful tips on how to take your medications and more. Our free Celebrating 65 program helps you make sense of social security, Medicare and more! For members enrolled in Harvard Pilgrims HMO products, prior authorization is required for any elective referral to a non-contracted provider. Set and achieve your personal health goals with one-on-one support from our personal health coaches. The following outlines who is responsible for obtaining prior authorizations: Under most Harvard Pilgrim plans, prior authorization is required for the following. This form allows you to authorize an individual to discuss and make decisions related to your health care and coverage. The information you are about to access may not meet accessibility standards for people with disabilities, including visual impairment, nor is it optimized for people using tablets or phones. Providers and office staff can refer to the following chart to review changes and updates to Harvard Pilgrim's Medical Necessity Guidelines (MNGs), information about newly developed MNGs, and more. Thats why we have a Care Team of registered nurses, clinical social workers and certified health coaches on hand to help answer your questions. Did you know you can get reimbursed for fees paid toward fitness facilities, certain complementary and alternative medicine services, weight management programs and more? Being a Harvard Pilgrim member is so rewarding! Together, we're delivering ever-better health care experiences to everyone in our diverse communities. Please reference the appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information. (Have your ID card handy.). Thats why we have a Care Team of registered nurses, clinical social workers and certified health coaches on hand to help answer your questions.
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