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Please choose the appropriate product below to view Harvard Pilgrim's product-specific Medical Review Criteria. Authorization forms To release or disclose information among designated individuals. Audrey Kleinberg, Director, Provider Relations & Communications 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. As of Jan. 1, 2020, Harvard Pilgrim began utilizing OptumRx as our pharmacy benefit manager. These standard forms can be used across payers and health benefit managers. 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. 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. Set and achieve your personal health goals with one-on-one support from our personal health coaches. To obtain a prior authorization, you or your provider should call . 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. Harvard Pilgrim Health Care . Discover which Medicare plan is right for you. Access all the Medicare Supplement Plan forms you need additional health insurance coverage, accident/injury questionnaire, authorizations, reimbursement, claim, representative designation and more. To claim reimbursement for qualifying childbirth classes covered under your plan, youll want to fill out theChildbirth Class Reimbursement form (pdf). Reimbursement forms, authorization forms, vision care claim forms, tax forms, plan documents and more all in one convenient location. Senior Manager, Provider Communications, Kristin Edmonston, Learn how! 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. Save big with exclusive discounts on a wide variety of health and well-being products and services. Routine inquiries regarding specific cases are triaged by Member Services and referred to appropriate Utilization Management (UM) staff via voicemail. Together, we're delivering ever-better health care experiences to everyone in our diverse communities. 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. Know your options and select the right care for your specific needs, day or night, virtually or in-person. Coverage Policies are developed to assist in administering health benefits and aid in the determination of medically necessary therapy. Learn how! 2022Harvard Pilgrim Health Care, Inc. All rights reserved. Call Member Services at (888) 888-4742 (TTY: 711). There are three variants; a typed, drawn or uploaded signature. Prior authorization is a process that requires either your provider or you to obtain approval from Harvard Pilgrim before receiving specific items and services. Managing out-of-pocket costs can be confusing. Understanding what your plan has to offer, Prior authorization, quantity limits & step therapy policies. 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. Please choose the appropriate product below to view Harvard Pilgrims product-specific Medical Review Criteria. Commercial Clinical/Authorization Policies, Medical Benefit Drugs: Medical Necessity Guidelines, About Our StrideSM (HMO)/(HMO-POS) Medicare Advantage Plans, Medicare Advantage Clinical/Auth. Together, we're delivering ever-better health care experiences to everyone in our diverse communities. 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. Home UVB treatment may also be considered in cases of chronic idiopathic hand and foot dermatitis refractory of other treatments and causing disability. Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. From personalized support in dealing with stressful health conditions or life changes to behavioral health tools, we make it easy to talk (or message!) 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 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. Specific items and services require that either your provider or you obtain approval (prior authorization) from Harvard Pilgrim. Look up drugs, get prices, find pharmacies and more. Youll want to fill out the Designation of Representative form. For prescription medications, be sure to use thePrescription Drug Reimbursement Claim form (pdf). 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. 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. Audrey Kleinberg, with a behavioral health professional. We are sorry. 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. For complete information, including coverage criteria and FDA-approved maximum dosage and frequency limits, refer to Harvard Pilgrim's Commercial Enjaymo Medical Policy. 1Must get prior authorization from Harvard Pilgrims list of contracted vendors. Production Coordinator. 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. Production Coordinator. Please bear with us as we work to upgrade this information to the same standards as the rest of our website. 2022Harvard Pilgrim Health Care, Inc. All rights reserved. To request authorization, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). 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. Access all the Medicare Advantage Stride forms you need enrollment, reimbursement, prescription drug, billing, representative designation, privacy and more. Know your care options before you need them. Harvard Pilgrims prior authorization requirements for commercial (HMO, POS, PPO) products are different from the requirements for itsStride (HMO) Medicare Advantage product. Our free Celebrating 65 program helps you make sense of social security, Medicare and more! Initial inquiries are referred to Member Services for review and response where appropriate. Specific items and services require that either your provider or you obtain approval (prior authorization) from Harvard Pilgrim. 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). Understanding what your plan has to offer, Prior authorization, quantity limits & step therapy policies. No results found for #SEARCH_KEYWORD# your search . 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! Commercial Clinical/Authorization Policies, Medical Benefit Drugs: Medical Necessity Guidelines, About Our StrideSM (HMO)/(HMO-POS) Medicare Advantage Plans, Medicare Advantage Clinical/Auth. 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. To claim reimbursement for covered behavioral health services received out of network, youll want to fill out the Behavioral Health Claim form. Choose My Signature. Access all the forms you need to help guide you on your health care journey with us. Managing out-of-pocket costs can be confusing. Physical and/or occupational therapy services require prior authorization if services are expected to exceed the members benefit limit. 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. 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. 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: Reimbursement forms, authorization forms, vision care claim forms, tax forms, plan documents and more all in one convenient location. Check out the comprehensive plans we have to help keep you and your family healthy. 2022Harvard Pilgrim Health Care, Inc. All rights reserved. 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 specific benefits subject to prior authorization may vary by product and/or employer group. Did you know you can get reimbursed for fees paid toward fitness facilities, certain complementary and alternative medicine services, weight management programs 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. 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? 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. Check out your options and take control of your health care needs today. Specific items and services require that either your provider or you obtain approval (prior authorization) from Harvard Pilgrim. Learn more about the prior authorization process in this section. . Audrey Kleinberg, 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. Know your options and select the right care for your specific needs, day or night, virtually or in-person. Thats why we have a Care Team of registered nurses, clinical social workers and certified health coaches on hand to help answer your questions. 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. Youll want to fill out the Confidential Exchange of Information form (pdf). We get it health care can be confusing. (Have your ID card handy.). 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. Here you can submit batch claim files, verify patient eligibility, send/receive specialty referrals, submit authorization requests, and more. If you are the Personal Representative (e.g., health care proxy, power of attorney, etc.) Were here to provide education and information about your medicines, including potential side effects, helpful tips on how to take your medications and more. Together, we're delivering ever-better health care experiences to everyone in our diverse communities. Please bear with us as we work to upgrade this information to the same standards as the rest of our website. 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). 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. An Activity Summary shows what we paid and what you owe your providers for medical care you received. Please bear with us as we work to upgrade this information to the same standards as the rest of our website. Learn more about the prior authorization process in this section. 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 Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. 2022 Harvard Pilgrim Health Care, Inc. All rights reserved. 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. Learn more about the prior authorization process in this section. (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. 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. Set and achieve your personal health goals with one-on-one support from our personal health coaches. Through OptumRx and submit mail service prescriptions to OptumRx Home Delivery, Selected Medical benefit drugs and biologicals. 5 p.m, outpatient speech/language therapy ( MA only ) discounts on a wide of! Big with exclusive discounts on a wide variety of health and well-being products and services by and/or. 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