Currentharvard pilgrim health carePolicy N/A

Prior Authorization Policy

Policy governing Harvard Pilgrim Health Care prior authorization procedures for selected medications, procedures, services and items; affects servicing and referring providers and applies to commercial members except where Choice/Choice Plus via Passport Connect are excluded.

Policy Summary

Payerharvard pilgrim health care

PolicyPrior Authorization Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionServicing providers must obtain prior authorization and should request it at least one week before the date of service when possible.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 business daysstandard clinical review time after receipt of medical information

next business dayMA prior auth decisions for post-acute admissions after receipt of required information

90 dayshonored prior authorizations from previous insurer for in-network providers

sleep studiesExample service managed by vendor

multipleExternal utilization management partners listed

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.

Scope and Applicability

Unless otherwise specified, this policy does not apply to members enrolled in the Choice or Choice Plus products offered through Passport Connect.

Authorizations for sleep-related durable medical equipment (sleep-related DME) must be requested directly through Harvard Pilgrim; do not submit sleep-related DME authorization requests through the external vendor that manages sleep studies.

Provider Responsibilities & Authorization Process

Prior Authorization

Prior Authorization Required

Harvard Pilgrim requires prior authorization for selected medications, procedures, services and items. Servicing and referring providers are responsible for obtaining authorization when required. When possible, request authorization at least one week before the date of service/admission to allow time for eligibility, benefits and medical necessity determination.

Providers must obtain prior authorization for selected services, medications, procedures and items.
Request authorizations prospectively when possible (≥1 week prior to service).
Failure to comply may result in administrative denial of payment (provider liable for denied claims) except where Maine law applies.

Prior Authorization

Non‑contracted Provider Referrals

Prior authorization from Harvard Pilgrim is required for all elective (non-urgent) HMO member referrals to non-participating providers regardless of location. POS and PPO members may self-refer per their benefit handbook. Harvard Pilgrim will authorize elective out-of-network referrals only when medically necessary or when services are not available in-network. Continuity-of-care and transitional authorizations may be issued in defined situations.

Elective HMO referrals to non-contracted providers require prior authorization.
Authorizations to non-contracted providers are limited and granted when in-network care is unavailable or to minimize disruption of ongoing care.
Complete the Out-of-Network Coverage at In-Network Level of Benefits and Continuity of Care Prior Authorization Form for requests.

Note

Vended Partner‑Managed Services

Harvard Pilgrim uses selected vended partners to manage utilization review for specific service categories. When a service is vendor-managed, authorization must be obtained through that partner and the partner's contact/process may differ from Harvard Pilgrim's standard process.

Some categories (cardiac diagnostics/interventional, outpatient advanced imaging, genetic and molecular testing, select joint surgeries, oncology protocols, spine services, sleep studies, etc.) are managed by vended partners such as Evolent and OncoHealth.
Authorization requests and status for vendor-managed services are handled through the vendor portals or phone numbers listed by program.
Providers should consult the Medical Necessity Guidelines on the Point32Health provider website for program-specific instructions.

Prior Authorization

Vendor‑Managed Prior Authorization (Specific Categories)

Services managed by vendors (for example: cardiac diagnostic tests/interventional procedures, outpatient advanced imaging, genetic and molecular diagnostic testing, select hip/knee/shoulder surgeries, oncology chemotherapy protocols, sleep studies, and non-emergent spine/interventional spine services) require authorization through the named vendor. Failure to obtain vendor-managed authorization may affect coverage and payment.

Cardiac diagnostics/interventional and advanced imaging — Evolent (www.radmd.com; 800-642-7543).
Genetic and molecular diagnostic testing — follow vendor instructions on Medical Necessity Guidelines.
Oncology outpatient therapies — OncoHealth via HPHConnect single sign‑on, fax 800-264-6128, phone 877-222-2021.
Sleep studies and many spine services — managed through Evolent; sleep-related DME requested directly through Harvard Pilgrim.

Step Therapy

Reference for Step‑Therapy / Criteria

Authorization criteria (including step therapy and other requirements) and up‑to‑date prior authorization policies are published in the Medical Necessity Guidelines on the Point32Health provider website. Providers must use these resources for current clinical criteria and step‑therapy rules when submitting authorization requests.

Refer to the Medical Necessity Guidelines (MNGs) and specific prior authorization policies at www.point32health.org/provider/ for current criteria and step therapy requirements.
Contact the Provider Service Center at 800-708-4414 for assistance.

Denial Risk

Change‑Notification Denial Risk

When an authorized service changes (for example, a change in date of service or in the authorized type of service — inpatient vs. surgical day care), Harvard Pilgrim must be informed. Failure to notify Harvard Pilgrim of changes to an authorized procedure may result in denial of the claim.

Notify Harvard Pilgrim promptly of any changes to an authorization (date, level or type of service).
Failure to report changes may result in claim denial.

Documentation Required

Required Information at Time of Request

Provide complete information with each authorization request to avoid delays: member identifiers, PCP and admitting provider names and NPIs, facility name/location/NPI, diagnosis and clinical information, service requested, and admission date (actual inpatient admission date when applicable). All requests must include valid NPIs for requesting and servicing providers.

Member name and Harvard Pilgrim ID number
PCP name and NPI; admitting provider name and NPI
Facility name, location and NPI
Diagnosis and clinical information, service requested, and admission date

Documentation Required

Medical Information Submission

To facilitate timely review, submit supporting medical information to the designated Harvard Pilgrim reviewer as soon as possible.

Include relevant clinical records and documentation with the request or provide them promptly when requested by the reviewer.

Note

Where to Find Authorization Status

Authorization status and approved transaction numbers for vendor‑managed services are available through HPHConnect, NEHEN, and the vendor portals (for example, Evolent's www.radmd.com). Check these systems for current status and transaction identifiers.

HPHConnect and NEHEN provide access to authorization status and approved transaction numbers.
Vendor portals (e.g., www.radmd.com) also display status and transaction numbers for vendor-managed reviews.

Key Terms

Prior authorization definition

DefinitionProspective review of medical necessity and clinical appropriateness required for selected medications, procedures, services and items.

Continuity of care prior authorization

DefinitionTemporary authorization to continue treatment with a non‑participating or prior‑plan authorized provider for a defined transitional period; prior authorizations from in‑network providers are honored for 90 days when a member switches to a Harvard Pilgrim Commercial plan.

Vended partner

DefinitionExternal vendor selected by Harvard Pilgrim to oversee utilization management for specified services (examples: Evolent, OncoHealth).

Example vendor — Evolent

Policy Background

This policy establishes the administrative processes Harvard Pilgrim uses to determine medical necessity and clinical appropriateness for elective, non-urgent services. It defines prior authorization requirements, outlines continuity-of-care provisions for transitioning members, and specifies special procedures for referrals to non-contracted providers and services managed by external vendor partners.