Currentharvard pilgrim health carePolicy N/A

Prior Authorization Requirements for Selected Services and Items

Defines which durable medical equipment, procedures, services, vendor-managed programs, and behavioral health services require prior authorization from Point32Health/Tufts Health Plan and directs providers where to find related medical necessity guidelines; applies to providers submitting requests for affected members.

Policy Summary

Payerharvard pilgrim health care

PolicyPrior Authorization Requirements for Selected Services and Items

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization per the applicable table and submit supporting clinical documentation via the listed fax numbers or secure provider portal.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4distinct prior-authorization tables

2026-03-01policy effective date

requiredprior authorization required

dozensservices listed (examples)

Prior Authorization Coverage Logic

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

General prior authorization coverage logic

Covered when prior authorization is obtained per the applicable table and Medical Necessity Guideline.

General authorization requirement: Service is subject to prior authorization when it appears in one of the four tables and the request follows the routing (Precertification Operations, Behavioral Health Department, Vendor Program) specified for that table.

Follow the referenced Medical Necessity Guideline on the Provider Resource Center for clinical criteria; for Tufts Health Together (Medicaid) EPSDT may allow coverage beyond these guidelines for members under age 21 with prior authorization.

Table 4 lists procedure codes that the Plan considers investigational and therefore not covered by the Plan. Providers should refer to the Provider Resource Center entry titled Noncovered Investigational Service for details.

Services and Codes Requiring Prior Authorization

Services/MNG names requiring prior authorization (examples)mixed

not listed as numeric codes

The document lists service and MNG names (e.g., Anterior Vertebral Body Tethering; Applied Behavior Analysis; Bariatric Surgery; Basivertebral Nerve Ablation; Blepharoplasty, Upper/Lower Eyelid, and Brow and/or Eyelid Ptosis Repair; Comprehensive Genomic Profiling with FoundationOne CDx or FoundationOne Liquid CDx; Continuous Glucose Monitoring and Diabetes Management Devices; Custom Fabricated Oral Appliances for OSA; Dental Procedures Requiring Hospital/Facility-Based Care; Endoscopic Sinus Surgeries; Gender Affirming Services; Genetic and Molecular Diagnostic Testing; Hematopoietic Stem-Cell Transplantation (HSCT); High-Cost DME, Adaptive Strollers and Speech Generating Devices; Home Accessibility Adaptations; Home Health Care Services; Hospice Services; Human Leukocyte Antigen Genotyping; Hyperbaric Oxygen Treatment; Hysterectomy, Certain Elective; Implantable Neurostimulators; Inpatient Acute and Post-Acute Levels of Care; Laser Vision Correction Surgery; Lower Limb Prostheses; Minimally Invasive Procedures for BPH; Mobile Cardiac Outpatient Telemetry (MCOT); Non-Emergency Medical Transportation (Ground/Air); Orthognathic Surgery; Osteogenesis Stimulators, Noninvasive; Out-of-Network Coverage at the In-Network Level; Outpatient PT/OT/SLP; Percutaneous Tibial Nerve Stimulation (PTNS); Power Operated Vehicles (POVs); Power Wheelchairs; Proton Beam Therapy; Procedures for Treatment of Symptomatic Varicose Veins; Reconstructive and Cosmetic Surgery; Solid Organ Transplant; Stereotactic Radiosurgery and Stereotactic Body Radiotherapy; Surgical Procedures for Treatment of Obstructive Sleep Apnea; Surgical Treatments for Lymphedema; Temporomandibular Joint (TMJ) Disorder Treatment; Tonic Motor Activation for Restless Leg Syndrome; Upper Limb Prostheses; Vertebroplasty and Kyphoplasty; Video Capsule Endoscopy; Whole Genome Sequencing; Children's Behavioral Health Initiative FIT; IHBS; IHT; Community Support Programs; Neuropsychological and Psychological Testing and Assessment; Recovery Support Navigator; Targeted Case Management ICC; Transcranial Magnetic Stimulation (rTMS); Vendor-managed programs (e.g., Evolent: Cardiac Diagnostic Testing/Interventional Procedures, Interventional Pain Management for Back Pain, Joint Surgeries - Hip/Knee/Shoulder, Outpatient Diagnostic Imaging, Spine Surgery and Cervical Spine Procedures; Carelon: Genetic Testing; EviCore: Sleep Studies and PAP Therapy) rather than specific CPT/HCPCS codes.

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for services listed in the plan tables (Table 1: DME/prosthetics/procedures via Precertification Operations; Table 2: behavioral health procedures via Behavioral Health Department; Table 3: vendor-managed programs; Table 4: investigational procedures not covered). Submit prior authorization requests via the specified portals or fax numbers for the appropriate department.

Table 1: DME, prosthetic items, procedures — prior authorization via Precertification Operations (portal or fax).
Table 2: Behavioral health procedure codes — prior authorization via Behavioral Health Department.
Table 4: Procedure codes considered investigational — not covered by the Plan.

Prior Authorization

Vendor-managed prior authorization routing

Certain services are routed to and managed by external vendor prior authorization programs. Providers must submit authorization requests to the vendor identified for the service in the Provider Resource Center rather than to the Plan's Precertification Operations when a vendor is listed.

Evolent manages: Cardiac diagnostic testing/interventional procedures; Interventional pain management for back pain; Joint surgeries (hip, knee, shoulder); Outpatient diagnostic/advanced imaging; Spine surgery and cervical spine procedures.
Carelon manages: Genetic testing.
EviCore manages: Sleep studies and PAP therapy prior authorization program.
Check the Provider Resource Center for the specific Service/Vendor name and submission instructions for each listed service.

Documentation Required

Submission and documentation

If prior authorization is required, submit supporting clinical documentation pertinent to the service request to the listed portals or fax numbers for the responsible department or vendor. Supporting documentation should align with the referenced Medical Necessity Guidelines and any vendor-specific requirements.

Use the Plan portal or the department-specific fax numbers for Precertification Operations for Table 1 requests.
Follow vendor submission paths (portal/fax) as specified on the Provider Resource Center for Table 3 services.
Include clinical notes, relevant imaging reports, prior conservative therapy documentation, and any other documentation requested by the vendor or Precertification Operations.

Denial Risk

Denial risk triggers

Claims payment is subject to eligibility and benefits on the date of service, coordination of benefits, referrals/authorizations, and utilization review rules. Missing prior authorization, required referrals, or incomplete documentation may result in denial of payment.

Verify member eligibility and benefits for the date of service prior to rendering services.
Ensure required referrals and prior authorizations are obtained and documented before claims submission.
Failure to follow vendor routing or to provide required clinical documentation may lead to denial.

Key Definitions

Medical Necessity Guidelines (MNG)

DefinitionConcise clinical coverage criteria developed from literature review, expert consultation, and regulatory/agency standards to determine coverage for selected therapeutic or diagnostic services; published on the Provider Resource Center.

PurposeUsed to make coverage decisions in conjunction with the member's benefit document and treating physician input, and to provide the basis for medical necessity determinations.

ScopeApply to selected services and items listed in the prior authorization tables; EPSDT may allow coverage beyond MNG for members under age 21 with prior authorization.

MaintenanceMNGs are revised and updated annually or more frequently when new evidence warrants changes.

LocationAll referenced Medical Necessity Guidelines are available on the Provider Resource Center (Point32Health Provider Resource link).

OpenPayer

Prior Authorization Requirements for Selected Services and Items

Prior Authorization Coverage Logic

Services and Codes Requiring Prior Authorization

What Providers Must Do

Policy Background

Key Definitions