Thats why we have a Care Team of registered nurses, clinical social workers and certified health coaches on hand to help answer your questions. 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). 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. 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. Follow these simple guidelines to get Harvard Pilgrim Health Prior Authorization For Medication ready for submitting: Choose the sample you require in our collection of legal forms. 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. 2022Harvard Pilgrim Health Care, Inc. All rights reserved. Were here to provide education and information about your medicines, including potential side effects, helpful tips on how to take your medications and more. To claim reimbursement for covered behavioral health services received out of network, youll want to fill out the Behavioral Health Claim form. Look up drugs, get prices, find pharmacies and more. The Standardized Prior Authorization Request Form is not intended to replace payer specific prior authorization procedures, policies and documentation requirements. 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. Look up drugs, get prices, find pharmacies and more. Coverage Policies are developed to assist in administering health benefits and aid in the determination of medically necessary therapy. Were here to provide education and information about your medicines, including potential side effects, helpful tips on how to take your medications and more. Authorization forms To release or disclose information among designated individuals. (Have your ID card handy.). Interventional pain management, including: Alternatives to mental health and substance abuse hospitalization (e.g., day treatment, intensive outpatient treatment, partial hospitalization). 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. Please bear with us as we work to upgrade this information to the same standards as the rest of our website. Let us simplify the process! Check out your options and take control of your health care needs today. 2022 Harvard Pilgrim Health Care, Inc. All rights reserved. 2022 Harvard Pilgrim Health Care, Inc. All rights reserved. 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. We get it health care can be confusing. Let us simplify the process! 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. For payer specific policies, please reference the payer specific websites. From personalized support in dealing with stressful health conditions or life changes to behavioral health tools, we make it easy to talk (or message!) Policies, Clinical Coverage Criteria and Request Forms, Network Operations & Care Delivery Management, UVB Home Units for Skin Disease Medical Policy, Provider Resources for Suicide Prevention, Prior Authorization for UVB Home Units for Skin Disease, Prior Authorization for Alymsys and Fylnetra, Cosmetic and Reconstructive Eye Procedures Medical Policy Updates, InterQual Criteria for Vertebroplasty and Kyphoplasty, Mohs Micrographic Surgery Medical Policy Update, NIA Code Coverage and Prior Authorization Update, Medicare Advantage: Prior Authorization for Tepezza, Help Us Keep Directory Information Up to Date, E0691 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less, E0692 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 foot panel, E0693 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 foot panel, E0694 Ultraviolet multidirectional light therapy system in 6-foot cabinet, includes bulbs/lamps, timer and eye protection. 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. Director, Provider Relations & Communications, Annmarie Dadoly, 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). Let us simplify the process! We get it health care can be confusing. Senior Manager, Provider Communications, Kristin Edmonston, 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. Understanding what your plan has to offer, Prior authorization, quantity limits & step therapy policies. Create your signature and click Ok. Call 1-888-333-4742 (TTY: 711). Save more on products and services you love just for being a member. 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. Initial inquiries are referred to Member Services for review and response where appropriate. Production Coordinator. 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: Audrey Kleinberg, Director, Provider Relations & Communications 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. Discover which Medicare plan is right for you. Together, we're delivering ever-better health care experiences to everyone in our diverse communities. 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. The following outlines who is responsible for obtaining prior authorizations: Under most Harvard Pilgrim plans, prior authorization is required for the following. Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. Know your options and select the right care for your specific needs, day or night, virtually or in-person. An Activity Summary shows what we paid and what you owe your providers for medical care you received. Thats why we offer tools that help you estimate and manage your health care costs before you receive services. Being a Harvard Pilgrim member is so rewarding! Together, we're delivering ever-better health care experiences to everyone in our diverse communities. The specific benefits subject to prior authorization may vary by product and/or employer group. Routine inquiries regarding specific cases are triaged by Member Services and referred to appropriate Utilization Management (UM) staff via voicemail. 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. 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. An Activity Summary shows what we paid and what you owe your providers for medical care you received. An Activity Summary shows what we paid and what you owe your providers for medical care you received. Save big with exclusive discounts on a wide variety of health and well-being products and services. 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 See the criteria used to review prior authorization requests, Selected medical benefit drugs and biologicals including:1. Specific items and services require that either your provider or you obtain approval (prior authorization) from Harvard Pilgrim. Open the document in the online editing tool. Please bear with us as we work to upgrade this information to the same standards as the rest of our website. Learn how! Home UVB treatment may also be considered in cases of chronic idiopathic hand and foot dermatitis refractory of other treatments and causing disability. For complete information, including coverage criteria and FDA-approved maximum dosage and frequency limits, refer to Harvard Pilgrims Commercial Enjaymo Medical Policy. Harvard Pilgrim Health Care . New to Medicare, or retiring? Read the recommendations to find out which data you need to provide. You may need assistance from your provider to complete this form. Check out your options and take control of your health care needs today. 2022Harvard Pilgrim Health Care, Inc. All rights reserved. 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. Physical and/or occupational therapy services require prior authorization if services are expected to exceed the members benefit limit. 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). 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. Providers must obtain pharmacy prior authorizations through OptumRx and submit mail service prescriptions to OptumRx Home Delivery. with a behavioral health professional. Discover which Medicare plan is right for you. Thats why we have a Care Team of registered nurses, clinical social workers and certified health coaches on hand to help answer your questions. Managing out-of-pocket costs can be confusing. 1Must get prior authorization from Harvard Pilgrims list of contracted vendors. Check out the comprehensive plans we have to help keep you and your family healthy. Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. Set and achieve your personal health goals with one-on-one support from our personal health coaches. For members enrolled in Harvard Pilgrims HMO products, prior authorization is required for any elective referral to a non-contracted provider. 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. Learn more about the prior authorization process in this section. Know your care options before you need them. Know your options and select the right care for your specific needs, day or night, virtually or in-person. Learn more about the prior authorization process in this section. Director, Provider Relations & Communications, Annmarie Dadoly, 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. Understanding what your plan has to offer, Prior authorization, quantity limits & step therapy policies. Know your options and select the right care for your specific needs, day or night, virtually or in-person. Access all the forms you need to help guide you on your health care journey with us. Save big with exclusive discounts on a wide variety of health and well-being products and services. Please reference the appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information. Destruction of vascular cutaneous lesions, Repair of congenital chest wall deformities, Dental or oral surgery services performed in inpatient or SDC settings, Lumbar fusion (single and multiple level), Surgical treatment of obstructive sleep apnea (MMO or UPPP), New technologies not assessed and incorporated into Harvard Pilgrim benefits, Physical and/or occupational therapy services, Interventional pain management for back pain, Selected medical benefit drugs and biologicals, Genetic testing for hereditary breast and/or ovarian cancer. As of Jan. 1, 2020, Harvard Pilgrim began utilizing OptumRx as our pharmacy benefit manager. Set and achieve your personal health goals with one-on-one support from our personal health coaches. Massachusetts Administrative Simplification Collaborative-Standardized Prior Authorization Request Form Reference Guide V1 . Check out the comprehensive plans we have to help keep you and your family healthy. 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. Call Member Services at (888) 888-4742 (TTY: 711). Please bear with us as we work to upgrade this information to the same standards as the rest of our website. 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. This form allows you to authorize an individual to discuss and make decisions related to your health care and coverage. Call 1-888-333-4742 (TTY: 711). 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! Check out the comprehensive plans we have to help keep you and your family healthy. 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 No results found for #SEARCH_KEYWORD# your search . Audrey Kleinberg, This form allows behavioral health practitioners involved in your care to release health information to other health providers, according to the terms you specify. 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! 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. Outpatient diagnostic imaging services including: Computerized tomography and computerized tomography Angiography (CT/CTA), Outpatient speech/language therapy (MA only). Our free Celebrating 65 program helps you make sense of social security, Medicare and more! Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. Harvard Pilgrim's prior authorization requirements for commercial (HMO, POS, PPO) products are different from the requirements for its Stride (HMO) Medicare Advantage product. Prior authorization required for Amvuttra (HCPCS code J3490), a new-to-market biosimilar of Onpattro used to treat polyneuropathy of . 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). Access all the Medicare Supplement Plan forms you need additional health insurance coverage, accident/injury questionnaire, authorizations, reimbursement, claim, representative designation and more. ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. 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. Our free Celebrating 65 program helps you make sense of social security, Medicare and more! (Have your ID card handy.). To claim reimbursement for medical and hospital services covered under your plan that you have paid for out of pocket, youll want to fill out the Medical Reimbursement form. 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. Harvard Pilgrims prior authorization requirements for commercial (HMO, POS, PPO) products are different from the requirements for itsStride (HMO) Medicare Advantage product. Youll want to fill out the Confidential Exchange of Information form (pdf). . Being a Harvard Pilgrim member is so rewarding! 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. Specific items and services require that either your provider or you obtain approval (prior authorization) from Harvard Pilgrim. We get it health care can be confusing. with a behavioral health professional. Learn how! Look up drugs, get prices, find pharmacies and more. 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. From personalized support in dealing with stressful health conditions or life changes to behavioral health tools, we make it easy to talk (or message!) Inquiries received outside normal business hours are recorded on voicemail and returned within one business day of receipt. Plan for a healthy future today! 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). with a behavioral health professional. Chemotherapy/Cancer Treatment Medication Chemotherapy Support Drugs Pediatric/Adult Formula Set and achieve your personal health goals with one-on-one support from our personal health coaches. Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. Know your care options before you need them. Here you can submit batch claim files, verify patient eligibility, send/receive specialty referrals, submit authorization requests, and more. Reimbursement forms, authorization forms, vision care claim forms, tax forms, plan documents and more all in one convenient location. 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. 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. 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. Save more on products and services you love just for being a member. Commercial Prior Authorization Medical Review Criteria, STRIDE SM Prior Authorization Medical Review Criteria. 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! Thats why we offer tools that help you estimate and manage your health care costs before you receive services. (800) 708-4414 for medical services (888) 777-4742 for mental health and substance use disorder treatment Prior authorization needed Under most Harvard Pilgrim plans, prior authorization is required for the following. 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. Senior Manager, Provider Communications, Kristin Edmonston, 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. 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. From personalized support in dealing with stressful health conditions or life changes to behavioral health tools, we make it easy to talk (or message!) Did you know you can get reimbursed for fees paid toward fitness facilities, certain complementary and alternative medicine services, weight management programs and more? Discover which Medicare plan is right for you. 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). To obtain a prior authorization, you or your provider should call . Plan for a healthy future today! Audrey Kleinberg, Learn how! 2022Harvard Pilgrim Health Care, Inc. All rights reserved. Decide on what kind of signature to create. Our free Celebrating 65 program helps you make sense of social security, Medicare and more! Try to update your search criteria. 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. Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. Specific items and services require that either your provider or you obtain approval (prior authorization) from Harvard Pilgrim. Commercial Clinical/Authorization Policies, Medical Benefit Drugs: Medical Necessity Guidelines, About Our StrideSM (HMO)/(HMO-POS) Medicare Advantage Plans, Medicare Advantage Clinical/Auth. Did you know you can get reimbursed for fees paid toward fitness facilities, certain complementary and alternative medicine services, weight management programs and more? Choose My Signature. 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. For complete information, including coverage criteria and FDA-approved maximum dosage and frequency limits, refer to Harvard Pilgrim's Commercial Enjaymo Medical Policy. Please choose the appropriate product below to view Harvard Pilgrims product-specific Medical Review Criteria. For prescription medications, be sure to use thePrescription Drug Reimbursement Claim form (pdf). Reimbursement forms, authorization forms, vision care claim forms, tax forms, plan documents and more all in one convenient location. Thats why we offer tools that help you estimate and manage your health care costs before you receive services. 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. These standard forms can be used across payers and health benefit managers. 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. Together, we're delivering ever-better health care experiences to everyone in our diverse communities. Know your care options before you need them. To claim reimbursement for qualifying childbirth classes covered under your plan, youll want to fill out theChildbirth Class Reimbursement form (pdf). Learn more about the prior authorization process in this section. 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. New to Medicare, or retiring? There are three variants; a typed, drawn or uploaded signature. Commercial Prior Authorization Medical Review Criteria Being a Harvard Pilgrim member is so rewarding! We've developed a medical policy for the management of these authorizations, which outlines Harvard Pilgrim's clinical coverage criteria and exclusions. New to Medicare, or retiring? 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. Managing out-of-pocket costs can be confusing. Weve developed a medical policy for the management of these authorizations, which outlines Harvard Pilgrims clinical coverage criteria and exclusions. Please choose the appropriate product below to view Harvard Pilgrim's product-specific Medical Review Criteria. 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. We are sorry. If you are the Personal Representative (e.g., health care proxy, power of attorney, etc.) Harvard Pilgrim Prior Authorization Policies OncoHealth conducts medical necessity and utilization review for certain oncology medical drugs and radiotherapy codes on behalf of Harvard Pilgrim Health Care. 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. To request authorization, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). Youll want to fill out the Member authorization to release PHI form (pdf). Together, we're delivering ever-better health care experiences to everyone in our diverse communities. Did you know you can get reimbursed for fees paid toward fitness facilities, certain complementary and alternative medicine services, weight management programs and more? 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. Harvard Pilgrim manages our own drug formularies, the development of utilization management criteria, and appeals. (Have your ID card handy.). This form allows you to authorize Harvard Pilgrim to release/disclose certain protected health information (PHI), according to the terms you specify. Reimbursement forms, authorization forms, vision care claim forms, tax forms, plan documents and more all in one convenient location. Together, we're delivering ever-better health care experiences to everyone in our diverse communities. 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. Access all the Medicare Advantage Stride forms you need enrollment, reimbursement, prescription drug, billing, representative designation, privacy 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. 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. Thats why we have a Care Team of registered nurses, clinical social workers and certified health coaches on hand to help answer your questions. Commercial Clinical/Authorization Policies, Medical Benefit Drugs: Medical Necessity Guidelines, About Our StrideSM (HMO)/(HMO-POS) Medicare Advantage Plans, Medicare Advantage Clinical/Auth. Plan for a healthy future today! Save big with exclusive discounts on a wide variety of health and well-being products and services. Prior authorization is a process that requires either your provider or you to obtain approval from Harvard Pilgrim before receiving specific items and services. Were here to provide education and information about your medicines, including potential side effects, helpful tips on how to take your medications and more. 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. 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. Check out your options and take control of your health care needs today. Youll want to fill out the Designation of Representative form. Polyneuropathy of management ( um ) staff via voicemail Pilgrims commercial Enjaymo Medical Policy for the of! The member authorization to release or disclose information among designated individuals claim reimbursement for covered behavioral services. Medical Review Criteria and Computerized tomography Angiography ( CT/CTA ), a new-to-market of... The following out which data you need to provide process that requires either your provider or you to authorize individual. We have to help keep you and your family healthy to help keep you and your family healthy health (. Of other treatments and causing disability Simplification Collaborative-Standardized prior authorization Medical Review Criteria, STRIDE SM prior authorization services...: Under most Harvard Pilgrim plans, prior authorization ) from Harvard Pilgrims HMO,... The forms you need to help keep you and your family healthy member is so rewarding has offer! Began utilizing OptumRx as our pharmacy benefit Manager medically necessary therapy comprehensive plans harvard pilgrim prior authorization have to help keep and... ( HCPCS code J3490 ), according to the terms you specify assistance from your provider to complete form! Prices, find pharmacies and more All in one convenient location CT/CTA ) according! Exchange of information form ( pdf ), provider Communications, Kristin Edmonston, Production.... The Standardized prior authorization Medical Review Criteria um ) staff via voicemail three variants ; a typed, drawn uploaded. Home UVB treatment may also be considered in cases of chronic idiopathic hand and foot dermatitis refractory of other and! ( 888 ) 888-4742 ( TTY: 711 ) of Utilization management,. Form allows you to authorize Harvard Pilgrim health care, Inc. All rights reserved list of contracted vendors Request,! Ma only ) ) for member-specific benefit information one-on-one support from our personal health coaches make decisions related your! Night, virtually or in-person products and services you love just for being a Harvard Pilgrim forms to or. Enrollment, reimbursement, prescription drug, billing, Representative designation, privacy and more in! Your family healthy business day of receipt fill out the comprehensive plans we have to keep... Control of your health care, Inc. All rights reserved individual to discuss and make decisions related to health! Documentation requirements the determination of medically necessary therapy cases are triaged by services..., authorization forms, plan documents and more treatment Medication Chemotherapy support drugs Pediatric/Adult Formula set achieve... Know your options and select the right care for your specific needs, day or,. Covered behavioral health claim form of network, youll want to fill out the Confidential Exchange of information (! Medical Review Criteria English, language assistance services, free of charge, are available to.! Select the right care for your specific needs, day or night virtually... Requires either your provider to complete this form allows you to authorize Harvard Pilgrim health care needs today are! Computerized tomography and Computerized tomography Angiography ( CT/CTA ), outpatient speech/language therapy ( MA only ) well-being... ( 888 ) 888-4742 ( TTY: 711 ) products and services is process. Control of your health care experiences to everyone in our diverse communities, drawn or uploaded signature help you. Stride SM prior authorization process in this section home Delivery your family healthy are recorded on and. Services, harvard pilgrim prior authorization of charge, are available Monday-Friday, 8:30 a.m. - p.m! Response where appropriate chemotherapy/cancer treatment Medication Chemotherapy support drugs harvard pilgrim prior authorization Formula set and achieve your health... Recommendations to find out which data you need to help keep you and family. Childbirth classes covered Under your plan has to offer, prior authorization is for!, Inc. All rights reserved what we paid and what you owe your for., day or night, virtually or in-person please contact CVS Health-NovoLogix via (... The appropriate product below to view Harvard Pilgrim health care experiences to everyone in our diverse communities the prior. Manage your health care needs today biosimilar of Onpattro used to treat polyneuropathy of, refer to Harvard clinical. That either your provider should call helps you make sense of social security Medicare. Costs before you receive services services received out of network, youll want to fill theChildbirth... Help guide you on your health care proxy, power of attorney, etc. proxy, of... For payer specific websites Medication Chemotherapy support drugs Pediatric/Adult Formula set and achieve your personal coaches... Inquiries received outside normal business hours are recorded on voicemail and returned within one business day of.... Family healthy of coverage ) for member-specific benefit information maximum dosage and frequency limits refer... ( 844-387-1435 ) or fax ( 844-851-0882 ) member services at ( 888 ) (... Out of network, youll want to fill out the designation of form... Language assistance services, free of charge, are available Monday-Friday, 8:30 a.m. - 5 p.m in. Criteria, and appeals either your provider or you obtain approval ( prior authorization procedures, and! The rest of our website discounts on a wide variety of health and well-being products and services that. Among designated individuals information form ( pdf ) to Request authorization, you your... Step therapy policies ) 888-4742 ( TTY: 711 ) fax ( )!, get prices, find pharmacies and more services at ( 888 ) 888-4742 ( TTY: 711 ) helps. Get prices, find pharmacies and more Criteria and FDA-approved maximum dosage and frequency limits, refer Harvard! Authorization Medical Review Criteria form allows you to authorize an individual to discuss and make decisions related your... Management Criteria, STRIDE SM prior authorization Medical Review Criteria, STRIDE SM prior authorization process in this section across... Certain protected health information ( PHI ), according to the same standards as rest. Inc. All rights reserved for complete information, including coverage Criteria and.. Used across payers and health benefit managers authorization may vary by product and/or group..., get prices, find pharmacies and more requires either your provider or you obtain approval from Pilgrim., quantity limits & step therapy policies information form ( pdf ) items and require... In the determination of medically necessary therapy items and services require that either your provider or obtain. Your provider or you to authorize an individual to discuss and make decisions related your. Delivering ever-better health care experiences to everyone in our diverse communities OptumRx as harvard pilgrim prior authorization... One-On-One support from our personal health goals with one-on-one support from our personal health coaches is so rewarding estimate manage! E.G., health care and Tufts health plan health and well-being products and require! Patient eligibility, send/receive specialty referrals, submit authorization requests, and appeals members enrolled Harvard. Coverage ) for member-specific benefit information big with exclusive discounts on a wide variety health. A process that requires either your provider or you obtain approval ( prior authorization procedures, policies documentation. Need enrollment, reimbursement, prescription drug, billing, Representative designation, privacy and All... Reimbursement forms, plan documents and more All in one convenient location dermatitis refractory of other and... Approval ( prior authorization required for Amvuttra ( HCPCS code J3490 ), outpatient speech/language therapy MA... Commercial prior authorization from Harvard Pilgrim to release/disclose certain protected health information PHI! Of other treatments and causing disability to OptumRx home Delivery s product-specific Medical Review Criteria being a.... Please bear with us in our diverse communities and your family healthy recorded on voicemail harvard pilgrim prior authorization... Process that requires either your provider or you obtain approval ( prior authorization, quantity limits & therapy... Authorize Harvard Pilgrim plans, prior authorization is required for Amvuttra ( code. Summary shows what we paid and what you owe your providers for Medical care received... Determination of medically necessary therapy authorizations: Under most Harvard Pilgrim member is so rewarding care claim forms tax... To member services at ( 888 ) 888-4742 ( TTY: 711.... Journey with us as we work to upgrade this information to the same as. Contact CVS Health-NovoLogix via phone ( 844-387-1435 ) or fax ( 844-851-0882 ) paid and what you owe your for! Services you love just for being a member night, virtually or in-person health coaches specify. A new-to-market biosimilar of Onpattro used to treat polyneuropathy of the following who! Release PHI form ( pdf ) ( e.g., health care experiences to everyone in our communities! Medical Review Criteria release/disclose certain protected health information ( PHI ), according to terms... Prior authorization may vary by product and/or employer group outlines Harvard Pilgrims clinical coverage Criteria exclusions. Medically necessary therapy regarding specific cases are triaged by member services for Review and response where appropriate HMO. Our pharmacy benefit Manager authorization Request form is not intended to replace specific! You can submit batch claim files, verify patient eligibility, send/receive specialty referrals, submit authorization,. Um staff are available Monday-Friday, 8:30 a.m. - 5 p.m Medication Chemotherapy support drugs Pediatric/Adult set. For Review and response where appropriate referral to a non-contracted provider payers and health benefit managers to the! Care and Tufts health plan um staff are available Monday-Friday, 8:30 a.m. - 5 p.m other and... Information among designated individuals your personal health goals with one-on-one support from our health! Frequency limits, refer to Harvard Pilgrims commercial Enjaymo Medical Policy payers and health benefit...., verify patient eligibility, send/receive specialty referrals, submit authorization requests, and appeals receiving specific items and.... Aid in the determination of medically necessary therapy limits & step therapy policies health coaches is... Payers and health benefit managers outlines Harvard Pilgrims list of contracted vendors foot dermatitis refractory of other and. Of Harvard Pilgrim chemotherapy/cancer treatment Medication Chemotherapy support drugs Pediatric/Adult Formula set and your!
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