CurrentHarvard Pilgrim Health CarePolicy N/A

Synagis (palivizumab) prior authorization form — Massachusetts standard

Standard Massachusetts prior authorization form for requesting coverage of Synagis (palivizumab) from Harvard Pilgrim Health Care; used by prescribers to document patient, clinical, and billing information to support medical necessity for RSV prophylaxis.

Policy Summary

PayerHarvard Pilgrim Health Care

PolicySynagis (palivizumab) prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization to Harvard Pilgrim Pharmacy Utilization Management using the provided form (phone/fax/online) with administration dates, number of doses requested, and billing codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1standard form for Synagis prior authorization

1.800.708.4414pharmacy utilization management phone

1.617.673.0988fax for PA requests

2014 AAPclinical criteria referenced

Coverage Criteria for Synagis (palivizumab)

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Initial eligibility per AAP categories

Covered when the prescriber documents that the patient meets criteria in one of the high‑risk categories below per 2014 AAP guidelines and provides supporting data:

Eligibility categories

Chronic Lung Disease (CLD) of prematurity: CLD of prematurity defined as gestational age ≤31 weeks, 6 days AND requirement for 21% oxygen for at least the first 28 days after birth; indicate if <12 months of age or 12–24 months of age with continued medical support during the 6‑month period before the second RSV season and document supplemental oxygen, diuretic therapy, or chronic corticosteroids as applicable.GA ≤31w6d; oxygen ≥28 days
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Chronic respiratory disease arising in perinatal period: Specify diagnosis such as Wilson-Mikity syndrome (P27.0), bronchopulmonary dysplasia originating in the perinatal period (P27.1), or other chronic respiratory disease originating in the perinatal period (P27.8); attach supporting clinical documentation.
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Congenital Heart Disease (hemodynamically significant): Patient <12 months of age at start of season with hemodynamically significant CHD (e.g., acyanotic heart disease receiving medication to control congestive heart failure and pending corrective surgery, moderate to severe pulmonary hypertension, or documented cyanotic heart disease); also includes patients 12–24 months undergoing cardiac transplant during RSV season (provide surgery date).age <12 months or 12-24 months for transplant
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Airway / Neuromuscular conditions: Patient <12 months of age at start of season with compromised handling of secretions due to a significant airway abnormality or neuromuscular condition; attach clinical notes describing the impairment.age <12 months
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Prematurity meeting criterion of gestational age ≤28 weeks, 6 days AND age <12 months at start of season.GA ≤28w6d and age <12 months at season start
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Other medical conditions: Cystic fibrosis or Down syndrome documented on form; attach relevant clinical history.
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Immunocompromised status: Documented immunocompromised condition as indicated on form; provide supporting clinical details.
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This Massachusetts standard Synagis® prior authorization form may not be accepted for requests under Medicare or Medicaid plans. Providers should verify plan-specific submission requirements before using this form and, when in doubt, contact Harvard Pilgrim Pharmacy Utilization Management for guidance.

The form is structured around the 2014 AAP high-risk categories for RSV prophylaxis; therefore, patients who do not meet the listed AAP-based high-risk conditions or the specific age and clinical thresholds (for example, the prematurity, CLD, CHD, or airway/neuromuscular criteria) are implied not to meet medical necessity for Synagis under this form.

Provider Submission, Documentation, and Billing Actions

Prior Authorization

How to Submit Prior Authorization and Contact Information

Prior authorization requests and billing information for medications (including Synagis) must be submitted to Harvard Pilgrim Health Care Pharmacy Utilization Management. Submission methods and contact details are listed below. For professionally administered medications (including buy-and-bill), complete servicing provider and billing provider information is required. Providers should attach relevant clinical documentation to support medical necessity; incomplete submissions may be returned or denied.

Submission: Phone 1.800.708.4414, Fax 1.617.673.0988, or online via https://point32health.promptpa.com
Include completed Massachusetts Standard Form for Synagis Prior Authorization when applicable
For Medicare or Medicaid members, verify the plan accepts this form before submission

Documentation Required

Current Treatment Documentation Required

Document current treatment status and dosing history when requesting authorization or reauthorization. This information is critical for determining continuation of therapy or initial approval.

Is the patient currently being treated with the drug requested? (Yes/No)
If yes: Date started; Date of last dose received; Number of doses received; Number of doses requested
For professionally administered medications: include Start Date, End Date, CPT/J-code, # of visits/units

Documentation Required

Required Form Fields and Attachments

Ensure the authorization form contains complete patient and prescriber identifiers, clinical rationale, and required attachments. Missing or incomplete fields may lead to delays, requests for additional information, or denial of the request.

Required form fields: patient name, DOB, gender, member ID, prescriber name, phone, specialty, secure fax, NPI, DEA, signature, and date
Clinical information: primary diagnosis and ICD code(s); gestational age and birth weight for infants; current weight and date recorded; concurrent medications and allergies; indication-specific checkboxes (e.g., CLD, CHD, prematurity) with supporting documentation as applicable
Attachments: clinical notes, hospital records, surgical dates, medication administration records, and any documentation demonstrating ongoing medical support (oxygen, diuretics, corticosteroids) where relevant
Professionally administered meds: complete servicing provider/facility and billing provider information; indicate if request is for reauthorization and provide CPT/J-code and units/visits

Denial Risk

Insufficient Clinical Criteria — Avoid Delays and Denials

Incomplete clinical criteria or missing documentation increases the risk of denial or delayed review. Common deficiencies include absent dosing history, missing diagnosis/ICD code, lack of gestational age or weight for infants, and missing servicing/billing provider identifiers for administered drugs.

Risk of denial if dosing history (start date, last dose, doses received) is not provided
Risk of delay if diagnosis and ICD-10 code(s) are omitted
Attach clinical notes for airway/neuromuscular conditions, congenital heart disease details, or evidence of ongoing medical support (oxygen, diuretics, corticosteroids) as applicable
Verify form acceptance for Medicare/Medicaid where noted to avoid submission rejection

Key Definitions

CLD — Chronic Lung Disease (CLD) of prematurity

TermChronic Lung Disease (CLD) of prematurity

Definition referenceDefined per 2014 AAP Committee on Infectious Disease and Bronchiolitis Guidelines

Associated criteriaUsed as an eligibility category on the Synagis prior authorization form

CLD definition (AAP 2014) — gestational age and oxygen requirement definition

AAP (2014) CLD definitionGestational age ≤31 weeks, 6 days AND requirement for 21% oxygen for at least the first 28 days after birth

Age-based eligibility boxes on form<12 months, or 12-24 months with continued medical support during 6-month period before second RSV season

Documented supportForm requests dates for supplemental oxygen, diuretic therapy, and chronic corticosteroids when applicable

Initial Authorization Criteria

Initial authorization — documentation that patient meets one of the AAP high-risk categories and age/therapy qualifiers

Initial authorization requires documentation that the patient meets one of the AAP high‑risk categories and relevant age/therapy qualifiers. Providers must complete required clinical and billing fields.

Initial therapy requirements: Documented primary diagnosis and ICD code(s); gestational age and birth weight; current weight; supporting evidence that the patient meets the specified AAP criteria (see CLD, CHD, prematurity, airway/neuromuscular entries); indicate age category (<12 months or 12–24 months where applicable) and list dates of supplemental oxygen, diuretic therapy, or chronic corticosteroid use when required.

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Form and billing data: Complete patient identifiers (name, DOB, member ID), prescriber information (NPI, DEA, secure fax, signature), and professionally administered medication section including start/end dates, servicing provider/facility, CPT code, J‑code, number of units/doses requested, and number of visits; attach clinical notes and any supporting documentation.

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Reauthorization / Continuation Criteria

Reauthorization / continuation — document prior dosing and request for ongoing treatment

For ongoing treatment, prescriber must document prior dosing and request reauthorization where applicable.

Reauthorization documentation: If request is for reauthorization, indicate 'Yes' on the form and provide date treatment was started, date of last dose received, number of doses previously received, and number of doses requested for the current authorization period; include dates for supplemental oxygen, diuretic, or chronic corticosteroid therapy where relevant and attach administration records.

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OpenPayer

Synagis (palivizumab) prior authorization form — Massachusetts standard

Coverage Criteria for Synagis (palivizumab)

Billing and Diagnosis Coding

Provider Submission, Documentation, and Billing Actions

Background and Purpose

Key Definitions

Initial Authorization Criteria

Reauthorization / Continuation Criteria

Quantity and Dose Requests

Site of Care and Billing Facility