Currentharvard pilgrim health carePolicy N/A

NH-HPHC-COM-list-mng

Lists services, items, procedures, and vendor-managed programs that require prior authorization for Harvard Pilgrim Health Care - New Hampshire commercial plans and identifies a table of procedure codes considered investigational and not covered. Indicates which department (Precertification, Behavioral Health, Vendor Program) handles authorization requests and references Medical Necessity Guidelines on the Provider Resource Center.

Policy Summary

Payerharvard pilgrim health care

PolicyNH-HPHC-COM-list-mng

Policy CodePolicy N/A

Change TypeAdministrative review

Effective DateMar 1, 2026

Next Review Date

Key ActionObtain prior authorization from the appropriate department (Precertification Operations, Behavioral Health, Vendor Program) before submitting claims; submission may be via portal or fax with supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

Reviewed by the Medical Policy Approval Committee (MPAC) on February 18, 2025 with effective date March 1, 2026.

3Authorization Tables (Precertification, Behavioral Health, Vendor)

1Investigational/Not Covered Table

40+Services/Items Listed in Table 1

Policy Overview

This document lists services, items, procedures, and vendor-managed programs that require prior authorization for Harvard Pilgrim Health Care - New Hampshire commercial plans and identifies a table of procedure codes considered investigational and not covered. All of the Medical Necessity Guidelines (MNG) referenced in this document can be found on our Provider Resource Center, which provides the detailed coverage criteria used to make coverage decisions.

Prior authorization is a condition of payment and must be obtained from the appropriate department (Precertification Operations, Behavioral Health, or Vendor Program) before submitting claims. If prior authorization is required, submit supporting clinical documentation pertinent to the service request to the fax numbers or via the secure online provider portal specified by the Plan.

Key Policy Facts

Payerharvard pilgrim health care

PolicyPrior Authorization Requirements (NH Commercial)

Policy NumberN/A

Effective Date2026-03-01

Last Review2025-02-18

Next Review

Key ActionObtain prior authorization from specified department prior to claim submission

Prior Authorization Requirement

Prior authorization is required for the following items and services; submission may be via portal or fax to specified departments.

Root

Table 1 - Precertification Operations Department
- Ankle Arthroscopy
- Anterior Vertebral Body Tethering
- Assisted Reproductive Technology Services-New Hampshire
- Bariatric Surgery
- Basivertebral Nerve Ablation
- Blepharoplasty, Upper/Lower Eyelid, and Brow and/or Eyelid Ptosis Repair
- Clinical Review of Dental Services in Medical Benefits
- Comprehensive Genomic Profiling with FoundationOne CDx or FoundationOne Liquid CDx: Comprehensive Genomic Profiling with FoundationOne® CDx or FoundationOne® Liquid CDx to Guide Cancer Treatment in Patients with Advanced Cancer
- Continuous Glucose Monitoring and Diabetes Management Devices
- Custom Fabricated Oral Appliances for OSA: Custom Fabricated Oral Appliances for Obstructive Sleep Apnea (OSA)
- Endoscopic Sinus Surgeries
- Gender Affirming Services
- Hematopoietic Stem-Cell Transplantation (HSCT)
- Home Health Care Services
- Hospice and Palliative Care Services
- Hyperbaric Oxygen Treatment
- Hysterectomy, Certain Elective
- Implantable Neurostimulators
- Implantable Pulmonary Artery Pressure Devices (CardioMEMS HF)
- Inpatient Acute and Post-Acute Levels of Care (Medical/Surgical)
- Lower Limb Prostheses
- Minimally Invasive Procedures for BPH: Minimally Invasive Procedures for the Treatment of Benign Prostatic Hypertrophy
- Mobile Cardiac Outpatient Telemetry (MCOT)
- Non-Emergency Medical Transportation (Ground/Air)
- Oral Formula and Enteral Nutrition
- Orthognathic Surgery for Severe Oral Maxillofacial Functional Disorders
- Osteogenesis Stimulators, Noninvasive
- Out-of-Network Coverage at In-Network Level and Continuity of Care: Out-of-Network Coverage at the In-Network Level of Benefits and Continuity of Care (All Plans)
- Percutaneous Tibial Nerve Stimulation (PTNS)
- Positive Airway Pressure Devices for Sleep Apnea
- Power Operated Vehicles (POVs)
- Power Wheelchairs
- Private Duty Nursing in the Home
- Procedures for Treatment of Symptomatic Varicose Veins: Procedures for the Treatment of Symptomatic Varicose Veins
- Proton Beam Therapy
- Reconstructive and Cosmetic Surgery
- Speech, Hearing, and Language Services
- Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
- Surgical Procedures for Treatment of Obstructive Sleep Apnea: Surgical Procedures for the Treatment Obstructive Sleep Apnea
- Surgical Treatments for Lymphedema
- Temporomandibular Joint (TMJ) Disorder Treatment
- Tonic Motor Activation for Restless Leg Syndrome: Tonic Motor Activation for the Treatment of Restless Leg Syndrome
- Total Joint Replacement-Ankle
- Upper Limb Prostheses
- Vertebroplasty and Kyphoplasty
- Video Capsule Endoscopy
Table 2 - Behavioral Health Department
- Applied Behavioral Analysis (ABA) Therapy and Habilitative Services for Autism Spectrum Disorder
- Neuropsychological and Psychological Testing and Assessment
- Transcranial Magnetic Stimulation (rTMS)
Table 3 - Vendor Managed Programs (Vendor Program authorization required)
- Cardiac Diagnostic Testing/Interventional Procedures (Evolent)
- Cervical Spine Procedures (Evolent)
- Genetic and Molecular Diagnostic Testing (Carelon)
- Interventional Pain Management for Back Pain (Evolent)
- Joint Surgeries-Hip (Evolent)
- Joint Surgeries-Knee (Evolent)
Table 4 - Investigational / Not Covered
- Noncovered Investigational Service: Procedure codes listed as Noncovered Investigational Service (see Provider Resource Center for details)

label': 'Table 1 - Precertification Operations Department'}

Investigational / Not Covered Procedure Codes

Investigational / Not Covered Procedure CodesmixedNot Covered

See Provider Resource Center

Procedure codes considered investigation and therefore not covered; specific codes listed on Provider Resource Center under 'Noncovered Investigational Service'

Actions for Providers

Prior Authorization

Obtain Prior Authorization

Prior authorization is required for services listed in Tables 1–3 and must be obtained from the appropriate department (Precertification Operations, Behavioral Health, Vendor Program) before submitting claims. Authorization requests may be submitted via the Plan’s provider portal or by fax and must include supporting clinical documentation.

Documentation Required

Submit Supporting Clinical Documentation

If prior authorization is required, submit supporting clinical documentation pertinent to the service request to the fax numbers or the provider portal specified by the Plan; prior authorization and submission of supporting documentation are conditions of payment.

Definitions and Reference

Definitions

Medical Necessity Guidelines (MNG)Guidelines developed to determine coverage for benefits, published on the Provider Resource Center, used along with the member's benefit document and physician input to make coverage decisions.

Specific procedure codes, vendor names, and additional authorization details are available on the Provider Resource Center. Some programs require vendor-specific authorization; Vendor Managed Programs listed include: Evolent (Cardiac Diagnostic Testing/Interventional Procedures, Cervical Spine Procedures, Interventional Pain Management for Back Pain, Joint Surgeries - Hip/Knee/Shoulder, Outpatient Diagnostic Imaging/Advanced Imaging, Sleep Studies, Spine Surgery), and Carelon (Genetic and Molecular Diagnostic Testing).

Revision History

2025-02-18Reviewed by MPAC

Reviewed by the Medical Policy Approval Committee (MPAC); effective date March 1, 2026; administrative approval/revision history; no clinical policy statement changes specified.

Policy Summary

Payerharvard pilgrim health care

PolicyNH-HPHC-COM-list-mng

Policy CodePolicy N/A

Change TypeAdministrative review

Effective DateMar 1, 2026

Next Review Date

SourceLink

On This Page

Joint Surgeries-Shoulder (Evolent)

Outpatient Diagnostic Imaging/Advanced Imaging (Evolent)

Sleep Studies (Evolent)

Spine Surgery (Evolent)