Referral, Notification, and Authorization—Authorization
Authorization Policy
Unless otherwise specified, information in this policy does not apply to members with the Choice or Choice Plus products offered through Passport
ConnectSM. For UnitedHealthcare’s related policies/procedures, please go to www.UnitedHealthcareOnline.com or call 800-708-4414.
Overview
Harvard Pilgrim requires prior authorization (prospective review of medical necessity and clinical appropriateness) for
selected medications, procedures, services and items.1 The prior authorization process is used to verify member eligibility, and facilitate the appropriate utilization of these elective, non-urgent services.
Requirements
Servicing providers are responsible for obtaining prior authorization from Harvard Pilgrim (when required).
• When possible, authorization should be requested at least one week prior to the date of service/admission to allow
Harvard Pilgrim time to determine eligibility, level of benefits and medical necessity.
• Failure to comply with Harvard Pilgrim’s authorization requirements will result in an administrative denial of the claim
payment (the provider is held liable for any denied claim).
• Members cannot be held liable for claims denied because a contracted provider did not obtain prior authorization.
Easy Access referring providers are responsible for obtaining prior authorization from Harvard Pilgrim for all non emergent referrals to “Authorized Access” providers for members enrolled in HMO, Best Buy HMO, and Tiered Copay HMO
Plans with Focus NetworkSM - MA Limited Network Option.
Decisions
Authorization and denial decisions are made in a timely manner that accommodates the clinical urgency of the situation. Decisions are communicated to the attending physician and the facility verbally and in writing, within standard
time frames.
Refer to Denials/Adverse Determination for administrative and clinical denial details.
Harvard Pilgrim’s UM reviewers are available to discuss any clinical denial with practitioners and providers impacted
by the denial decision. Written notification of denial decisions includes information explaining how to contact the UM
reviewer.
Procedures and Services That Require Prior Authorization
Harvard Pilgrim’s prior authorization requirements are subject to change. For up-to-date information, contact the
Provider Service Center at 800-708-4414 and select the option for the Referral/Authorization Unit, or visit our provider website at www.harvardpilgrim.org.
Harvard Pilgrim requires prior authorization for selected elective procedures and services including:
• Admission to skilled or sub-acute nursing facilities
- Breast reconstruction
• Admission to rehabilitation hospitals (including inpatient pulmonary rehabilitation) and long-term acute
hospitals
- Breast reduction
- Repair of congenital chest deformities (pectus carinatum, pectus excavatum, Poland Syndrome)
• Bariatric surgery2 including:
- Eye procedures (blepharoplasty, brow ptosis repair,
blepharoptosis repair)
- Gastric stapling
- Gastric lap banding for obesity
- Biliopancreatic diversion with duodenal switch
- Nasal procedures (rhinoplasty, septoplasty,
rhinophyma treatment)
- Gastric bypass surgeries
- Removal of breast implants
- Laparoscopy, surgical, gastric restrictive procedure,
(i.e., sleeve gastrectomy)
- Skin procedures (scar revision, treatment of hemangiomas and port wine stains)
• Gender reassignment surgeries
• Selected non-urgent Behavioral Health services (see
Behavioral Health Care Authorization)
• Genetic testing for hereditary breast and/or ovarian
cancer
• Cholecystectomy
• HMO member referrals to out-of-network providers
• Selected cosmetic and reconstructive surgery
including:
• Hip Arthroplasty and Total Hip Replacement
• Home health services including infusion therapy
- Eye procedures (blepharoplasty, brow ptosis repair,
blepharoptosis repair)
Harvard Pilgrim Health Care—Provider Manual
• Hospice care
D.16
(continued)
August 2016
Referral, Notification, and Authorization Policies and procedures—Authorization
Authorization Policy (cont.)
• Hysterectomy
• Implantable Neurostimulators (deep brain stimulators,
gastric stimulators, sacral nerve stimulators, spinal cord
stimulators, vagus nerve stimulators)
• New technologies (i.e., items or services for which Harvard Pilgrim has not made a coverage determination)
• Non-emergent Lumbar Spine Surgeries, including:
- Lumbar fusion — Single and multiple level
• Infant formula and parenteral nutrition
- Lumbar Decompression
• Infertility services including IUI, IVF, embryo transfer,
FET, GIFT, ZIFT, ICSI, donor egg procedures, donor
sperm, cryopreservation of sperm or eggs, sperm storage/banking, MESA and TESE
- Lumbar Microdiscectomy
(See Spine Utilization Management and Prior Authorization document)
• Outpatient imaging services including CT scans,
PET scans MRIs, MRAs, and nuclear cardiology (see
Outpatient Advanced Imaging Authorization)
• Inpatient or SDC admissions for dental care including
extractions and oral or periodontal surgery
• Interventional Spine Pain Managment services,
including:
•Outpatient pulmonary rehabilitation
- Facet joint injections
• Outpatient Physical Therapy, Occupational Therapy,
and Speech/Language Therapy (see Outpatient Rehabilitative Therapies Authorization)
- Facet neurolysis
• Panniculectomy and/or removal of excess tissue
- Epidural injections
(See Spine Utilization Managment and Prior Authorization document)
•Preimplantation Genetic Testing
• Selected durable medical equipment (DME)
• Knee Arthroplasty
- Long-Term Continuous Glucose Monitoring Systems
(CGMS)
• Lyme/Tick-Borne Diseases — Parenteral Antibiotic Use
• Medical Benefit Drugs including:
- Prosthetic Devices (upper and lower limbs)
Actemra1
NPlate
- Miscellaneous DME (HCPCS E1399 or A9999)
Aloxi
Opdivo
Anzemet
Orencia2
• Sinus Surgeries (frontal sinusotomy, functional endoscopic sinus surgery [FESS], nasal/sinus cavity debridement following FESS, maxillary sinusotomy)
Aralast NP
Prolastin
Cimzia1
Prolia
Cinryze
Remicade
Elelyso
Rituxan
Emend
Sandostatin
Entyvio
Simponi-Aria
• Temporomandibular joint (TMJ) surgery (therapeutic
arthroscopy, arthroplasty including discectomy, joint
replacement)
Glassia
Soliris
• Transcranial Magnetic Stimulation (TMS)
H.P. Acthar Gel
Stelara
• Urinary Incontinence Surgeries
Ilaris
Tysabri
• Varicose veins treatment
Immune Globulins
VPRIV
Keytruda
Xgeva
Lemtrada
Xolair
Lumizyme
Yervoy
Harvard Pilgrim also requires prior authorization for all
non-emergent services rendered by “Authorized Access”
providers for members enrolled in HMO, Best Buy HMO,
and Tiered Copay HMO Plans with Focus NetworkSM MA Limited Network Option.
Myozyme
Zemaira
• Sleep Studies/Sleep Therapies (see Sleep Studies
Authorization)
• Surgical treatment of obstructive sleep apnea and/or
obstructive sleep disorder
Harvard Pilgrim’s Medical Review Criteria are available
on-line in the Medical Management section of Harvard
Pilgrim’s provider site at www.harvardpilgrim.org.
1For
the subcutaneous formulation of this drug
please contact MedImpact at 800-788-2949 for
authorization.
A copy of current Medical Review Criteria may also be
obtained by contacting Harvard Pilgrim’s Provider Service Center at 800-708-4414. Select the option for the
Referral/Authorization Unit.
2Must
be obtained through Harvard Pilgrim’s
Specialty Pharmacy program.
Action Required
When possible, please request authorization at least one week prior to the date of service/admission to allow Harvard
Pilgrim time to determine eligibility, level of benefits and medical necessity.
• The facility, PCP or specialist may request authorization.
Harvard Pilgrim Health Care—Provider Manual
(continued)
D.17
August 2016
Referral, Notification, and Authorization Policies and procedures—Authorization
Authorization Policy (cont.)
Request prior authorization through one of the following channels.
Electronic
Submit a transaction record with required information using the HPHConnect or NEHEN transaction service.
•D
etailed HPHConnect instructions are available at www.harvardpilgrim.org/providers. (Refer to the user guides at
HPHConnect/User Guides.)
• For NEHEN instructions, refer to your NEHEN documentation.
Harvard Pilgrim Response
The request pends for receipt of medical information and evaluation. Evaluation is completed within two business days
after receipt of medical information. The final status will be available online.
Fax or Telephone
Send required information to Harvard Pilgrim’s Referral/Authorization Unit.
• Fax
800-232-0816
• Phone
800-708-4414, and select the option for the Referral/Authorization Unit.
Harvard Pilgrim Response
The request pends for receipt of medical information and evaluation. Evaluation is completed within two business days
after receipt of medical information. The decision will be communicated by fax or telephone within one business day.
Information Required
The following information is required for an authorization request:
• Member’s name and Harvard Pilgrim identification number
• PCP’s name and National Provider Identifier (NPI)
• Admitting provider’s name and NPI
• Facility’s name, location and NPI
• Diagnosis and clinical information
• Service requested (i.e., admission, procedure, etc.)
• Admission date (must be the actual date the member was admitted to inpatient status)
All requests for services must be submitted with a valid NPI for the requesting and servicing providers.
For referrals to “Authorized Access” providers (for members enrolled in HMO, Best Buy HMO, and Tiered Copay HMO
Plans with Focus NetworkSM - MA Limited Network Option), the name and NPI of the requested “Authorized Access”
provider is also required.
Medical Information
To facilitate the authorization process, submit medical information to the designated Harvard Pilgrim reviewer as soon
as possible.
Authorization Changes
Harvard Pilgrim must be informed when any change to an authorized procedure occurs, such as a change in the date of
service or a change in the authorized type of service (i.e., inpatient or surgical day care).
Electronic
dit the existing transaction record or submit a new transaction record, using the HPHConnect or NEHEN transaction
E
service.
• Detailed HPHConnect instructions are available at www.harvardpilgrim.org/providers. (Refer to the user guides at
HPHConnect/User Guides.)
• For NEHEN instructions refer to your NEHEN documentation.
Telephone or Mail
Send changes to Harvard Pilgrim’s Referral /Authorization Unit.
• Mail
arvard Pilgrim Health Care
H
Referral and Authorization Unit
1600 Crown Colony Drive
Quincy, MA 02169
Harvard Pilgrim Health Care—Provider Manual
• Fax
800-232-0816
• Phone800-708-4414, and select the option for
the Referral/Authorization Unit.
(continued)
D.18
August 2016
Referral, Notification, and Authorization Policies and procedures—Authorization
Authorization Policy (cont.)
Action Required
When possible, request authorization for all services and items at least one week prior to the date of service/admission
to allow Harvard Pilgrim time to determine eligibility, level of benefits and medical necessity.
To obtain information regarding authorization for:
Service
Refer to
Behavioral health
Behavioral Health Services Authorization
Cholecystectomy
Harvard Pilgrim’s Medical Review Criteria for Cholecystectomy Policy
Dental/oral surgery
Dental and Oral Surgery Authorization
Diagnostic imaging services
Outpatient Advanced Imaging Authorization
Durable medical equipment (DME)
Durable Medical Equipment Authorization
Total hip arthroscopy (THA) and total hip replacement (THR)
Harvard Pilgrim’s Medical Review Criteria for THA and THR Policy
Home health care — including home infusion and home
hospice services
Home Health Services Authorization
Hysterectomy
Harvard Pilgrim’s Medical Review Criteria for Hysterectomy Policy
Implantable neurostimulators
Harvard Pilgrim’s Medical Review Criteria for Implantable Neurostimulators Policy
Infertility services
Infertility Services Authorization
Inpatient admissions to skilled nursing facilities (SNFs),
inpatient rehabilitation facilities (IRFs), and long-term acute
hospitals (LTACs)
Skilled Nursing Facility and Rehabilitation Facility Authorization
Intra-facility transfer
Intra-Facility Transfer Authorization
Effective 7/1/14 — Non-emergent Interventional spine pain
services including:
• Epidural injections
• Facet joint injections
• Facet neurolysis
Spine Management and Prior Authorization
Knee arthroplasty
Harvard Pilgrim’s Medical Review Criteria for Knee Arthroplasty
Policy
Non-urgent/emergent out-of-network services—including
referrals to non-participating providers (not applicable to
POS/PPO members)
Non-Participating Provider Services Authorization
ffective 07/01/14 — Non-emergent lumbar spine surgeries,
E
including:
• Lumbar fusion — Single and multiple level
• Lumbar decompression
• Lumbar microdiscectomy
Spine Management and Prior Authorization
Prescription
Medication Prior Authorization Program
Sinus Surgeries
Harvard Pilgrim’s Medical Review Criteria for Sinus Surgeries Policy
Sleep studies and sleep therapies
Sleep Study/Sleep Therapies Authorization
Harvard Pilgrim HMO, Best Buy HMO, and Tiered Copay
HMO Plans with Focus NetworkSM — MA Limited Network
Option
Product Portfolio: Product and Product Administration — HMO
Plans
Urinary incontinence surgeries
Harvard Pilgrim’s Medical Review Criteria for Urinary Incontinence
Surgeries Policy
To obtain authorization for: Service
Contact
Behavioral health services
Harvard Pilgrim's Behavioral Health Access Center at
888-777-4742. (Referral from PCP is not required.)
Cholecystectomy
Fax a completed Cholecystectomy Request Form to the Referral/Auth
Unit at 800-232-0816
Harvard Pilgrim Health Care—Provider Manual
(continued)
D.19
August 2016
Referral, Notification, and Authorization Policies and procedures—Authorization
Authorization Policy (cont.)
Service
Contact
Diagnostic imaging services
NIA by telephone at 800-642-7543
Authorization status and approved transaction numbers are also
available to servicing providers through HPHConnect and NEHEN.
Status and transaction numbers can be accessed through NIA’s website at www.radmd.com
Total hip arthroscopy (THA) and total hip replacement (THR)
Fax a completed THA and THR Prior Auth Form to the Referral/Auth
Unit at 800-232-0816
Hysterectomy
Fax a completed Hysterectomy Request Form to the Referral/Auth
Unit at 800-232-0816
Implantable neurostimulators
Fax a completed Implantable Neurostimulators Request Form to the
Referral/Auth Unit at 800-232-0816
Infant formula and enteral nutrition
Fax a completed Formula Request Form to the Referral/Auth Unit at
800-232-0816
Knee arthroplasty
Fax a completed Knee Arthroplasty Prior Auth Form to the Referral/
Auth Unit at 800-232-0816
Knee arthroscopy
Fax a completed Knee Arthroscopy Prior Auth Form to the Referral/
Auth Unit at 800-232-0816
Non-emergent interventional spine pain services and lumbar
spine surgeries
NIA by telephone at 800-642-7543
Authorization status and approved transaction numbers are also
available to servicing providers through HPHConnect and NEHEN.
Status and transaction numbers can be accessed through NIA’s website at www.radmd.com
Outpatient pulmonary rehabilitation
Fax a completed Harvard Pilgrim Outpatient Pulmonary Rehab
Request Form to the Ref/Auth Unit at 800-232-0816
Outpatient speech therapy (ST) treatment (MA only)
Fax a completed Outpatient Rehabilitative Therapies Auth Form to
the Referral/Auth Unit at 800-232-0816
Sinus surgeries
Fax a completed Sinus Surgeries Prior Auth Form to the Referral/
Auth Unit at 800-232-0816
Sleep studies and sleep therapies
• Call CCN (Monday-Friday 7 a.m. -7 p.m. EST) at
888-511-0401
• Providers may also log on to HPHConnect and link to CCN secure
web portal
Urinary incontinence surgeries
Fax a completed Urinary Incontinence Surgeries Prior Auth Form to
the Referral/Auth Unit at 800-232-0816
Related Policy
Coordination of Benefits (COB) Claims
PUBLICATION HISTORY
11/21/11
updated telephone extension information and fax numbers
12/15/11
minor edits for clarity
01/01/12
removed First Seniority Freedom information
02/15/12
minor edits for clarity
03/15/12
minor edits to "Action Required" sections for clarity
04/01/12
added referral/authorization information for Focus NetworkSM - MA Limited Network Option
08/15/13
updated authorization list for clarity
11/15/13
added gender reassignment surgeries
01/15/13
reviewed; added medical benefit drugs; minor edits for clarity
04/15/13
added spine pain management services
07/25/14
added Rhode Island implementation pending regulatory approval information
03/15/15
reviewed, minor edits for clarity
07/15/15
added additional surgical services for prior authorization
08/15/16
reviewed; updated procedures and services that require authorization
1Harvard
Pilgrim medical necessity review requirements are not applicable in Rhode Island.
ensure quality of care Harvard Pilgrim directs members requiring bariatric surgery to designated Centers of Excellence that have met stringent quality
criteria established by the American College of Surgeons, or the American Society for Bariatric Surgery. Procedures for most HMO members must be
performed at facilities identified as bariatric Centers of Excellence in Harvard Pilgrim’s Provider Directory. Procedures for most POS/PPO members must
be performed at designated Centers of Excellence to be covered at in-network cost-sharing amounts. (Note: Harvard Pilgrim's Center of Excellence program is not applicable to Fully Insured HMO, PPO, or POS members with Maine insurance contracts.)
3Rhode Island implementation pending regulatory approval.
2To
Harvard Pilgrim Health Care—Provider Manual
D.20
August 2016