Call Member Services at (888) 888-4742 (TTY: 711). Check out your options and take control of your health care needs today. Here you can submit batch claim files, verify patient eligibility, send/receive specialty referrals, submit authorization requests, and more. Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. The information you are about to access may not meet accessibility standards for people with disabilities, including visual impairment, nor is it optimized for people using tablets or phones. We get it health care can be confusing. The information you are about to access may not meet accessibility standards for people with disabilities, including visual impairment, nor is it optimized for people using tablets or phones. Audrey Kleinberg, Director, Provider Relations & Communications Thats why we offer tools that help you estimate and manage your health care costs before you receive services. There are three variants; a typed, drawn or uploaded signature. 2022Harvard Pilgrim Health Care, Inc. All rights reserved. Routine inquiries regarding specific cases are triaged by Member Services and referred to appropriate Utilization Management (UM) staff via voicemail. Being a Harvard Pilgrim member is so rewarding! Massachusetts Medication Request form (MA providers only) (pdf), New Hampshire Harvard Pilgrim standard form (for all other providers) (pdf), Harvard Pilgrim standard form (for all other providers) (pdf). Providers and office staff can refer to the following chart to review changes and updates to Harvard Pilgrim's Medical Necessity Guidelines (MNGs), information about newly developed MNGs, and more. Please bear with us as we work to upgrade this information to the same standards as the rest of our website. These criteria are objective and based on current clinical and medical evidence and applied with consideration of individual needs and characteristics (e.g., age, comorbidities, prior treatment and complications), and the availability of services within the local delivery system. Know your options and select the right care for your specific needs, day or night, virtually or in-person. For complete information, including coverage criteria and FDA-approved maximum dosage and frequency limits, refer to Harvard Pilgrim's Commercial Enjaymo Medical Policy. Director, Provider Relations & Communications, Annmarie Dadoly, Access all the Medicare Advantage Stride forms you need enrollment, reimbursement, prescription drug, billing, representative designation, privacy and more. Commercial Prior Authorization Medical Review Criteria To obtain a prior authorization, you or your provider should call . To coordinate medical or dental benefits for members covered by another health, dental or Medicare insurance plan, youll want to completethe Coordination of Benefits questionnaire. Know your care options before you need them. of a member, please complete and submit the Personal Representative Cover Form with your legal documentation in order to be documented in Harvard Pilgrims system. Know your care options before you need them. You may be eligible to claim reimbursement for a COVID-19 at-home test that you have paid for out of pocket, check eligibility and find instructions on ourCOVID-19 testing and coverage page. Managing out-of-pocket costs can be confusing. Know your care options before you need them. Save more on products and services you love just for being a member. UM staff are available Monday-Friday, 8:30 a.m. - 5 p.m. Access all the Medicare Supplement Plan forms you need additional health insurance coverage, accident/injury questionnaire, authorizations, reimbursement, claim, representative designation and more. Prior Authorization A standardized, or "uniform," prior authorization (PA) form may be required in certain states to submit PA requests to a health plan for review, along with the necessary clinical documentation. Here you'll find information on a variety of health topics: behavioral health conditions, healthy tips for any age, managing chronic pain and choosing your primary care provider. Whether you need help managing your weight or controlling your blood pressure, a health coach will support, educate and motivate you to achieve your health goals. To claim reimbursement for your childs covered dental care received outside the dental network, youll want to fill out the Pediatric Dental Claim form (pdf). Check out the comprehensive plans we have to help keep you and your family healthy. (Have your ID card handy.). Massachusetts Administrative Simplification Collaborative-Standardized Prior Authorization Request Form Reference Guide V1 . Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. Senior Manager, Provider Communications, Kristin Edmonston, 2022 Harvard Pilgrim Health Care, Inc. All rights reserved. Reimbursement forms, authorization forms, vision care claim forms, tax forms, plan documents and more all in one convenient location. From the most commonly asked questions to understanding your plan, our Help section provides everything you need to know to successfully navigate your health care journey. LOGIN or REGISTER Key Contacts Provider Service Center (commercial): 800-708-4414 Referral and Authorization Requests: 800-708-4414 Care Management 888-888-4742, x 31035 E-Services/EDI-Direct: Together, we're delivering ever-better health care experiences to everyone in our diverse communities. Open the document in the online editing tool. Decide on what kind of signature to create. 1Must get prior authorization from Harvard Pilgrims list of contracted vendors. Know your options and select the right care for your specific needs, day or night, virtually or in-person. Thats why we offer tools that help you estimate and manage your health care costs before you receive services. Save big with exclusive discounts on a wide variety of health and well-being products and services. The Standardized Prior Authorization Request Form is not intended to replace payer specific prior authorization procedures, policies and documentation requirements. Thats why we have a Care Team of registered nurses, clinical social workers and certified health coaches on hand to help answer your questions. Here you'll find information on a variety of health topics: behavioral health conditions, healthy tips for any age, managing chronic pain and choosing your primary care provider. To claim reimbursement for travel expenses that are primarilly for and essential to covered services that are restricted or prohibited in your state of residence as a result of state law, youll want to fill out the Travel Benefit Reimbursement form. Save more on products and services you love just for being a member. Commercial Clinical/Authorization Policies, Medical Benefit Drugs: Medical Necessity Guidelines, About Our StrideSM (HMO)/(HMO-POS) Medicare Advantage Plans, Medicare Advantage Clinical/Auth. Please reference the appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information. Reimbursement forms, authorization forms, vision care claim forms, tax forms, plan documents and more all in one convenient location. Follow the step-by-step instructions below to design your prior authorization for select hip knee Harvard pilgrim hEvalth care: Select the document you want to sign and click Upload. For members enrolled in Harvard Pilgrims HMO products, prior authorization is required for any elective referral to a non-contracted provider. Coverage Policies are developed to assist in administering health benefits and aid in the determination of medically necessary therapy. The following HCPCS codes related to UVB home units will require prior authorization: For complete information, please refer to Harvard Pilgrims UVB Home Units for Skin Disease Medical Policy. Let us simplify the process! Thats why we have a Care Team of registered nurses, clinical social workers and certified health coaches on hand to help answer your questions. To claim reimbursement for an approved health club or fitness facility membership that you have paid for out of pocket, youll want to fill out the Fitness Reimbursement form. Check out the comprehensive plans we have to help keep you and your family healthy. Authorization forms To release or disclose information among designated individuals. Learn more about the prior authorization process in this section. Check out the comprehensive plans we have to help keep you and your family healthy. No prior authorization from Harvard Pilgrim is needed to receive care Coverage for preventative services such as physicals and routine eye exams, as well as necessary services and emergency care Built-In discount and saving programs for products & services such nutrition/weight management, eyewear, and medicine services with a behavioral health professional. Look up drugs, get prices, find pharmacies and more. Set and achieve your personal health goals with one-on-one support from our personal health coaches. Please choose the appropriate product below to view Harvard Pilgrims product-specific Medical Review Criteria. For HMO, POS and PPO plans, to claim reimbursement for prescription medications covered under your plan that you have paid for out of pocket, youll want to complete the Prescription Drug Reimbursement Claim form (pdf). As of Jan. 1, 2020, Harvard Pilgrim began utilizing OptumRx as our pharmacy benefit manager. Audrey Kleinberg, Prior authorization for Enjaymo a classical complement inhibitor indicated to decrease the need for red blood cell transfusion due to hemolysis in adults with cold agglutinin disease may be granted when the following criteria are met: To request authorization, please contact CVS HealthNovoLogix via phone (844-387-1435) or fax (844-851-0882). Managing out-of-pocket costs can be confusing. Learn more about the prior authorization process in this section. From preparing for maternity leave to dealing with being a working parent, find resources to support you no matter where you are in the journey of reproductive health, pregnancy and parenthood. Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. To claim reimbursement for approved complementary and alternative medicine services that you have paid for out of pocket (if your plan includes this reimbursement benefit), youll want to fill out the Complementary and Alternative Medicine Reimbursement form. Production Coordinator. Check out your options and take control of your health care needs today. To claim reimbursement for covered behavioral health services received out of network, youll want to fill out the Behavioral Health Claim form. Production Coordinator. Let us guide you toward information on how to apply for Social Security benefits, what types of health care options are available to you under Medicare, and much more. For complete information, including coverage criteria and FDA-approved maximum dosage and frequency limits, refer to Harvard Pilgrims Commercial Enjaymo Medical Policy. Read the recommendations to find out which data you need to provide. Let us simplify the process! Together, we're delivering ever-better health care experiences to everyone in our diverse communities. We get it health care can be confusing. Together, we're delivering ever-better health care experiences to everyone in our diverse communities. Thats why we offer tools that help you estimate and manage your health care costs before you receive services. To claim reimbursement for qualifying childbirth classes covered under your plan, youll want to fill out theChildbirth Class Reimbursement form (pdf). For payer specific policies, please reference the payer specific websites. Our free Celebrating 65 program helps you make sense of social security, Medicare and more! Outpatient diagnostic imaging services including: Computerized tomography and computerized tomography Angiography (CT/CTA), Outpatient speech/language therapy (MA only). We've developed a medical policy for the management of these authorizations, which outlines Harvard Pilgrim's clinical coverage criteria and exclusions. We are sorry. Discover which Medicare plan is right for you. Were here to provide education and information about your medicines, including potential side effects, helpful tips on how to take your medications and more. We make staying healthy fun, informative and engaging with a variety of activities on topics like eating healthy, mindfulness, financial wellness, stress management and more! Set and achieve your personal health goals with one-on-one support from our personal health coaches. Authorize Harvard Pilgrim to release/disclose your health information Authorize behavioral health practitioners to release your health information Authorize someone to act as your health care representative Managing out-of-pocket costs can be confusing. Choose My Signature. Practicing mindfulness involves breathing methods, guided imagery and more to help the mind to refocus on the present moment, relax the body and mind, and reduce stress. Let us guide you toward information on how to apply for Social Security benefits, what types of health care options are available to you under Medicare, and much more. Policies, Clinical Coverage Criteria and Request Forms, Network Operations & Care Delivery Management, Medical Drug Dosage and Frequency Exception Criteria Expanded, Prescription Infant Formula Coverage Update, Rate Increase for Early Intervention Providers, Reduced Payment for Late Notification of Inpatient Admissions, Help Us Keep Directory Information Up to Date, Medical Policy for Routine Costs Associated with Clinical Trials, 2022 Home Care Seasonal Flu Vaccine Fee Schedule, Reminder: Medicare Part B Step Therapy Policy, Enjaymo to be Covered With Prior Authorization, Prior Authorization for Solid Organ Transplants, Documented diagnosis of primary cold agglutinin disease, Prescribed by, or in consultation with, a hematologist, Documented history of at least one blood transfusion in the previous six months before the initiation of treatment with Enjaymo. Thats why we have a Care Team of registered nurses, clinical social workers and certified health coaches on hand to help answer your questions. Specific items and services require that either your provider or you obtain approval (prior authorization) from Harvard Pilgrim. Senior Manager, Provider Communications, Kristin Edmonston, Learn how! Director, Provider Relations & Communications, Annmarie Dadoly, with a behavioral health professional. Plan for a healthy future today! From personalized support in dealing with stressful health conditions or life changes to behavioral health tools, we make it easy to talk (or message!) Specific items and services require that either your provider or you obtain approval (prior authorization) from Harvard Pilgrim. Weve developed a medical policy for the management of these authorizations, which outlines Harvard Pilgrims clinical coverage criteria and exclusions. In order to verify your dependents eligibility as a disabled adult which includes authorization to obtain protected health information youll need to fill out the Disabled Adult Dependent Verification form (pdf). ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Harvard Pilgrim will require prior authorization for UVB home units for skin disease, effective for dates of service beginning Nov. 1, 2022, for members of our Commercial plans. Learn more about the prior authorization process in this section. These standard forms can be used across payers and health benefit managers. Try to update your search criteria. Being a Harvard Pilgrim member is so rewarding! From personalized support in dealing with stressful health conditions or life changes to behavioral health tools, we make it easy to talk (or message!) Prior authorization is a process that requires either your provider or you to obtain approval from Harvard Pilgrim before receiving specific items and services. Discover which Medicare plan is right for you. Harvard Pilgrim manages our own drug formularies, the development of utilization management criteria, and appeals. From personalized support in dealing with stressful health conditions or life changes to behavioral health tools, we make it easy to talk (or message!) Audrey Kleinberg, An Activity Summary shows what we paid and what you owe your providers for medical care you received. From the most commonly asked questions to understanding your plan, our Help section provides everything you need to know to successfully navigate your health care journey. Please bear with us as we work to upgrade this information to the same standards as the rest of our website. Were here to provide education and information about your medicines, including potential side effects, helpful tips on how to take your medications and more. For all products, when prior authorization is required, Harvard Pilgrim uses written criteria based on sound clinical evidence to evaluate the medical appropriateness of health care services. (Have your ID card handy.). This form allows behavioral health practitioners involved in your care to release health information to other health providers, according to the terms you specify. Did you know you can get reimbursed for fees paid toward fitness facilities, certain complementary and alternative medicine services, weight management programs and more? We make staying healthy fun, informative and engaging with a variety of activities on topics like eating healthy, mindfulness, financial wellness, stress management and more! Learn how! If you are the Personal Representative (e.g., health care proxy, power of attorney, etc.) . Did you know you can get reimbursed for fees paid toward fitness facilities, certain complementary and alternative medicine services, weight management programs and more? Did you know you can get reimbursed for fees paid toward fitness facilities, certain complementary and alternative medicine services, weight management programs and more? Understanding what your plan has to offer, Prior authorization, quantity limits & step therapy policies. Check out your options and take control of your health care needs today. Outpatient diagnostic imaging services, including: Computerized tomography and computerized tomography angiography (CT/CTA), Magnetic resonance imaging and magnetic resonance angiography (MRI/MRA), Diagnostic CT colonoscopy (virtual colonoscopy, CT colonography), For hereditary breast and/or ovarian cancer, Collection, storage and cryopreservation (freezing) of eggs, sperm or embryos, Embryo transfer and frozen embryo transfer (FET), Microsurgical epididymal sperm aspiration (MESA), Intravenous antibiotics for treatment of Lyme disease/tick-borne diseases, Acthar HP (repository corticotropin injection), Advate (factor VIII (antihemophilic factor, recombinant), Adynovate (factor VIII (antihemophilic factor, recombinant), Afstyla (factor VIII (antihemophilic factor, recombinant), Alphanate/VWF Complex/Human (factor VIII [antihemophilic factor, recombinant]), AlphaNine SD (factor IX (antihemophilic factor, purified, non-recombinant), Alprolix (factor IX (antihemophilic factor, recombinant), Aralast NP (alpha-1 proteinase inhibitor), BeneFIX (factor IX (antihemophilic factor, recombinant), Berinert (c-1 esterase inhibitor [human]), Deferoxamine Mesylate (deferoxamine mesylate), Doxil (doxorubicin hydrochloride, liposomal), DOXOrubicin HCl Liposomal (doxorubicin hydrochloride, liposomal), Eligard (leuprolide acetate (for depot suspension), Eloctate (factor VIII (antihemophilic factor, recombinant), Factor IX NOC (factor IX (antihemophilic factor, recombinant), Gemcitabine HCl (gemcitabine hydrochloride), Helixate FS (factor VIII (antihemophilic factor, recombinant), Hemofil M (factor VIII (antihemophilic factor, recombinant), Humate-P (factor VIII (antihemophilic factor, recombinant), Hyqvia (immune globulin infusion 10% [human] recombinant human hyaluronidase), Ixinity (factor IX [antihemophilic factor, recombinan]), Koate-DVI (factor VIII [antihemophilic factor, recombinant]), Kogenate FS/Kogenate FS Bio-Set (factor VIII [antihemophilic factor, recombinant]), Kovaltry (factor VIII [antihemophilic factor, recombinant]), Levoleucovorin Calcium (levoleucovorin calcium), Lupron Depot - Prostate Cancer (leuprolide acetate), Mircera (epoetin beta/methoxy polyethylene glycol), Mitoxantrone HCl (mitoxantrone hydrochloride), Monoclate-P (factor VIII [antihemophilic factor, recombinant]), Mononine (factor IX (antihemophilic factor, purified, non-recombinant), Novoeight (factor VIII [antihemophilic factor, recombinant]), NovoSeven RT (factor VIIa [antihemophilic factor, recombinan]), Nuwiq (factor VIII [antihemophilic factor, recombinant]), Obizur (factor VIII [antihemophilic factor, recombinant]), Octreotide Acetate (octreotide, non-depot form for subcutaneous or intravenous injection), Profilnine/Profilnine SD (factor IX, complex), Prolastin-C (alpha-1 proteinase inhibitor), Recombinate (factor VIII [antihemophilic factor, recombinant]), Rixubis (factor IX [antihemophilic factor, recombinant]), Ruconest (c1 esterase inhibitor [recombinant]), Supartz/Supartz FX (hyaluronan or derivative), Trelstar/Terlstar Mixject (triptorelin pamoate), Wilate (von Willebrand factor complex [human]), Xyntha/Xyntha Solofuse (factor VIII [antihemophilic factor, recombinant]), Prosthetic devices for upper and lower limbs. New to Medicare, or retiring? Practicing mindfulness involves breathing methods, guided imagery and more to help the mind to refocus on the present moment, relax the body and mind, and reduce stress. Commercial Clinical/Authorization Policies, Medical Benefit Drugs: Medical Necessity Guidelines, About Our StrideSM (HMO)/(HMO-POS) Medicare Advantage Plans, Medicare Advantage Clinical/Auth. Youll want to fill out the Confidential Exchange of Information form (pdf). Physical and/or occupational therapy services require prior authorization if services are expected to exceed the members benefit limit. You may need assistance from your provider to complete this form. Specific items and services require that either your provider or you obtain approval (prior authorization) from Harvard Pilgrim. Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. Please bear with us as we work to upgrade this information to the same standards as the rest of our website. Harvard Pilgrim's prior authorization requirements for commercial (HMO, POS, PPO) products are different from the requirements for its Stride (HMO) Medicare Advantage product. Commercial Prior Authorization Medical Review Criteria, STRIDE SM Prior Authorization Medical Review Criteria. 2022 Harvard Pilgrim Health Care, Inc. All rights reserved. (Have your ID card handy.). The following outlines who is responsible for obtaining prior authorizations: Under most Harvard Pilgrim plans, prior authorization is required for the following. Let us simplify the process! Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. To ensure that a claim for an injury or illness resulting from an accident, such as a slip and fall, is processed correctly, simply complete the Insurance, Liability and Recovery questionnaire. Call 1-888-333-4742 (TTY: 711). Were here to provide education and information about your medicines, including potential side effects, helpful tips on how to take your medications and more. Interventional pain management, including: Alternatives to mental health and substance abuse hospitalization (e.g., day treatment, intensive outpatient treatment, partial hospitalization). Youll want to fill out the Designation of Representative form. Whether you need help managing your weight or controlling your blood pressure, a health coach will support, educate and motivate you to achieve your health goals. We get it health care can be confusing. See the criteria used to review prior authorization requests, Selected medical benefit drugs and biologicals including:1. New to Medicare, or retiring? Harvard Pilgrim Health Care . Together, we're delivering ever-better health care experiences to everyone in our diverse communities. Set and achieve your personal health goals with one-on-one support from our personal health coaches. Providers must obtain pharmacy prior authorizations through OptumRx and submit mail service prescriptions to OptumRx Home Delivery. Harvard Pilgrims prior authorization requirements for commercial (HMO, POS, PPO) products are different from the requirements for itsStride (HMO) Medicare Advantage product. No results found for #SEARCH_KEYWORD# your search . Harvard Pilgrim will require prior authorization for orthognathic surgery for Commercial members, effective for dates of service beginning Oct. 1, 2022, and the following InterQual criteria subsets will be used for medical review: Bone Augmentation, Mandible Bone Augmentation, Maxilla Osteotomy, Anterior Segment, Mandible Osteotomy, LeFort I Coverage of the purchase of a UVB home phototherapy unit may be authorized when the member has a diagnosis of moderate-to-severe psoriasis and a history of frequent psoriasis flares that require home therapy for suppression, or when the member has a diagnosis of severe atopic dermatitis/eczema, has failed first line therapies, and meets all the criteria on the policy specific to that indication. with a behavioral health professional. Initial inquiries are referred to Member Services for review and response where appropriate. Our free Celebrating 65 program helps you make sense of social security, Medicare and more! Being a Harvard Pilgrim member is so rewarding! Reimbursement forms, authorization forms, vision care claim forms, tax forms, plan documents and more all in one convenient location. Call 1-888-333-4742 (TTY: 711). Prior authorization required for Amvuttra (HCPCS code J3490), a new-to-market biosimilar of Onpattro used to treat polyneuropathy of . Effective for dates of service beginning June 20, 2022, Harvard Pilgrim will cover the medication Enjaymo (HCPCS code J3490), with prior authorization, for members of our Commercial plans. Youll want to fill out the Member authorization to release PHI form (pdf). To claim reimbursement for an approved weight management program that you have paid for out of pocket (if your plan includes this reimbursement benefit), youll want to fill out the Weight Management Reimbursement form. Let us guide you toward information on how to apply for Social Security benefits, what types of health care options are available to you under Medicare, and much more. For prescription medications, be sure to use thePrescription Drug Reimbursement Claim form (pdf). New to Medicare, or retiring? Together, we're delivering ever-better health care experiences to everyone in our diverse communities. ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Understanding what your plan has to offer, Prior authorization, quantity limits & step therapy policies, Member authorization to release PHI form (pdf), Confidential Exchange of Information form (pdf), Disabled Adult Dependent Verification form (pdf), Childbirth Class Reimbursement form (pdf), Prescription Drug Reimbursement Claim form (pdf). We make staying healthy fun, informative and engaging with a variety of activities on topics like eating healthy, mindfulness, financial wellness, stress management and more! Practicing mindfulness involves breathing methods, guided imagery and more to help the mind to refocus on the present moment, relax the body and mind, and reduce stress. Plan for a healthy future today! Download a Standard Prior Authorization Request form If your patient's plan requires Prior Authorization for a service or procedure listed below, please complete the Standard Prior Authorization Requestform in addition to the applicable form below. Access all the forms you need to help guide you on your health care journey with us. An Activity Summary shows what we paid and what you owe your providers for medical care you received. From preparing for maternity leave to dealing with being a working parent, find resources to support you no matter where you are in the journey of reproductive health, pregnancy and parenthood. From the most commonly asked questions to understanding your plan, our Help section provides everything you need to know to successfully navigate your health care journey. The specific benefits subject to prior authorization may vary by product and/or employer group. 2022Harvard Pilgrim Health Care, Inc. All rights reserved. Discover which Medicare plan is right for you. Chemotherapy/Cancer Treatment Medication Chemotherapy Support Drugs Pediatric/Adult Formula To request authorization, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). Know your options and select the right care for your specific needs, day or night, virtually or in-person. Learn how! To allow Harvard Pilgrim representatives to speak to a parent about the health coverage and care of their dependent (under age 18) when parent is not listed on that minors policy, aStatement of Parental Rights form (pdf) will need to be completed. From preparing for maternity leave to dealing with being a working parent, find resources to support you no matter where you are in the journey of reproductive health, pregnancy and parenthood. This form allows you to authorize an individual to discuss and make decisions related to your health care and coverage.
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