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. Access all the Medicare Advantage Stride forms you need enrollment, reimbursement, prescription drug, billing, representative designation, privacy and more. Please choose the appropriate product below to view Harvard Pilgrim's product-specific Medical Review Criteria. 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. Let us simplify the process! Director, Provider Relations & Communications, Annmarie Dadoly, 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. An Activity Summary shows what we paid and what you owe your providers for medical care you received. Know your care options before you need them. The following outlines who is responsible for obtaining prior authorizations: Under most Harvard Pilgrim plans, prior authorization is required for the following. Managing out-of-pocket costs can be confusing. 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. These standard forms can be used across payers and health benefit managers. 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. 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. Chemotherapy/Cancer Treatment Medication Chemotherapy Support Drugs Pediatric/Adult Formula Check out your options and take control of your health care needs today. with a behavioral health professional. Thats why we offer tools that help you estimate and manage your health care costs before you receive services. Did you know you can get reimbursed for fees paid toward fitness facilities, certain complementary and alternative medicine services, weight management programs and more? Save more on products and services you love just for being a member. 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. Harvard Pilgrim's prior authorization requirements for commercial (HMO, POS, PPO) products are different from the requirements for its Stride (HMO) Medicare Advantage product. Youll want to fill out the Confidential Exchange of Information form (pdf). Reimbursement forms, authorization forms, vision care claim forms, tax forms, plan documents and more all in one convenient location. 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. 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. 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. Set and achieve your personal health goals with one-on-one support from our personal health coaches. 2022 Harvard Pilgrim Health Care, Inc. All rights reserved. Save more on products and services you love just for being a member. Know your care options before you need them. Director, Provider Relations & Communications, Annmarie Dadoly, We've developed a medical policy for the management of these authorizations, which outlines Harvard Pilgrim's clinical coverage criteria and exclusions. From personalized support in dealing with stressful health conditions or life changes to behavioral health tools, we make it easy to talk (or message!) Outpatient diagnostic imaging services including: Computerized tomography and computerized tomography Angiography (CT/CTA), Outpatient speech/language therapy (MA only). The specific benefits subject to prior authorization may vary by product and/or employer group. 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! with a behavioral health professional. Weve developed a medical policy for the management of these authorizations, which outlines Harvard Pilgrims clinical coverage criteria and exclusions. 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. Call Member Services at (888) 888-4742 (TTY: 711). Plan for a healthy future today! Together, we're delivering ever-better health care experiences to everyone in our diverse communities. Decide on what kind of signature to create. From personalized support in dealing with stressful health conditions or life changes to behavioral health tools, we make it easy to talk (or message!) Together, we're delivering ever-better health care experiences to everyone in our diverse communities. Know your care options before you need them. Learn how! 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. Plan for a healthy future today! Home UVB treatment may also be considered in cases of chronic idiopathic hand and foot dermatitis refractory of other treatments and causing disability. 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. 2022Harvard 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. Please bear with us as we work to upgrade this information to the same standards as the rest of our website. 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. For complete information, including coverage criteria and FDA-approved maximum dosage and frequency limits, refer to Harvard Pilgrim's Commercial Enjaymo Medical Policy. Please reference the appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information. 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. Learn how! 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 Commercial Prior Authorization Medical Review Criteria, STRIDE SM Prior Authorization Medical Review Criteria. Massachusetts Administrative Simplification Collaborative-Standardized Prior Authorization Request Form Reference Guide V1 . 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. Commercial Clinical/Authorization Policies, Medical Benefit Drugs: Medical Necessity Guidelines, About Our StrideSM (HMO)/(HMO-POS) Medicare Advantage Plans, Medicare Advantage Clinical/Auth. 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 covered behavioral health services received out of network, youll want to fill out the Behavioral Health Claim form. Access all the Medicare Supplement Plan forms you need additional health insurance coverage, accident/injury questionnaire, authorizations, reimbursement, claim, representative designation and more. Being a Harvard Pilgrim member is so rewarding! Thats why we have a Care Team of registered nurses, clinical social workers and certified health coaches on hand to help answer your questions. New to Medicare, or retiring? We are sorry. Save big with exclusive discounts on a wide variety of health and well-being products and services. 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. 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). An Activity Summary shows what we paid and what you owe your providers for medical care you received. Physical and/or occupational therapy services require prior authorization if services are expected to exceed the members benefit limit. Our free Celebrating 65 program helps you make sense of social security, Medicare and 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. Interventional pain management, including: Alternatives to mental health and substance abuse hospitalization (e.g., day treatment, intensive outpatient treatment, partial hospitalization). ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. You may need assistance from your provider to complete this form. 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. 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. Routine inquiries regarding specific cases are triaged by Member Services and referred to appropriate Utilization Management (UM) staff via voicemail. We get it health care can be confusing. Set and achieve your personal health goals with one-on-one support from our personal health coaches. Save more on products and services you love just for being a member. Inquiries received outside normal business hours are recorded on voicemail and returned within one business day of receipt. Please bear with us as we work to upgrade this information to the same standards as the rest of our website. (Have your ID card handy.). Reimbursement forms, authorization forms, vision care claim forms, tax forms, plan documents and more all in one convenient location. Create your signature and click Ok. 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 complete information, including coverage criteria and FDA-approved maximum dosage and frequency limits, refer to Harvard Pilgrims Commercial Enjaymo Medical Policy. 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 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. 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. Please choose the appropriate product below to view Harvard Pilgrims product-specific Medical Review Criteria. 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 payer specific policies, please reference the payer specific websites. 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 the comprehensive plans we have to help keep you and your family healthy. This form allows behavioral health practitioners involved in your care to release health information to other health providers, according to the terms you specify. Open the document in the online editing tool. 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. 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). Discover which Medicare plan is right for you. Initial inquiries are referred to Member Services for review and response where appropriate. Learn how! 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. 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. 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). 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). Access all the forms you need to help guide you on your health care journey with us. Discover which Medicare plan is right for you. As of Jan. 1, 2020, Harvard Pilgrim began utilizing OptumRx as our pharmacy benefit manager. 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. Check out your options and take control of your health care needs today. 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. Call 1-888-333-4742 (TTY: 711). Understanding what your plan has to offer, Prior authorization, quantity limits & step therapy policies. 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. 2022 Harvard Pilgrim Health Care, Inc. All rights reserved. There are three variants; a typed, drawn or uploaded signature. Audrey Kleinberg, Director, Provider Relations & Communications Are expected to exceed the members benefit limit benefit managers a Medical policy Collaborative-Standardized prior authorization form! Typed, drawn or uploaded signature, day or night, virtually or in-person and causing disability:. According to the same standards as the rest of our website //oncohealth.us/medicalpolicies/harvardpilgrim/ '' > < >. To your health care and Tufts health plan authorization to release PHI (. 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