Past authorization for care

Prior license the a usage that requires either your provider or you to obtain approval from Harvard Walk for receiving specific items and services. 

The specific benefits subject to past authorization may modify by product and/or employers group. Please reference the appropriate member materials (e.g., Benefit Operation, Certificate of Coverage) for member-specific benefit information.

Anybody belongs responsible?

The following outlines who your responsible for conserve prior authorizations:

  • If you have an HMO plan and see an in-network donor (doctor or clinician), the provider is responsible for obtaining prior authorization for select items and services noted is the following section.
  • If thee have a POS or PPO product (including Erreichbar America) and your seeing an in-network provider (doctor or clinician) in and service section (as defined in your Benefit Handbook), the provider can responsible for obtaining precedent authorization for select items and services notice in the following section.
  • While you have a POS conversely PPO product (including Access America) and your provider is out of network used your plan press is an in-network provider outside of the service zone (as defined to yours Benefit Handbook), my provider conversely you are responsible for obtaining prior power.

 

To keep a ago authorization, you or your provider should call ...

Prior authorization needed

Go most Harvard Pilgrim plans, prior authorization is required for the later. For members enrolled in Harvard Pilgrim’s HMO products, before authorization is required for any elective recommending to a non-contracted contributor.

Visit the criteria used up check priority authorization requests

  • Implantable neurostimulators
  • Interventional distress management, including: 1
    • Epidural injections
    • Characteristic joint injections
    • Facet neurolysis
  • Non-emergent inpatient admissions1
  • Alternatives up mental health and skin abuse hospitalization (e.g., day treatment, intensive outpatient treatment, partial hospitalization)
  • Outpatient diagnosis imaging services, including:
    • Computerized tomography the computerized tomography angiography (CT/CTA)
    • Magnetic resonance imaging and magnetic resonance angiography (MRI/MRA)
    • Atomic cardiological
    • Positron emanation tomography (PET)
    • Medical CT colonoscopy (virtual colonoscopy, CT colonography)
  • Sleep diagnostic, including:
    • Home button attended sleep studies
  • Molecular diagnostic management
  • Used Gaucher sick
  • Forward hereditary breast and/or ovarian cancer
  • Pre-implantation genetic testing (PGT)
  • E.g., visiting nurse, home infusion
  • Collection, saving the cryopreservation (freezing) to eggs, samenleiter or imported
  • Donor oocyte
  • Donor spermatozoon
  • Gamete intra-fallopian transfer (GIFT)
  • Intra-cytoplasmic sperm injection (ICSI)
  • Intra-uterine insemination (IUI) 
  • In-vitro fertilization (IVF) 
  • Embryo transport and frozen embryos takeover (FET)
  • Microsurgical epididymal samenzellen goal (MESA)
  • Testicular sperm extraction (TESE) 
  • Zygote intra-fallopian transfer (ZIFT)
  • Immune globulin (IVIg)
  • Intravenous antibiotics for dental of Lyme disease/tick-borne related

Selected medicine how drugs and biologicals including:1

  • Abraxane (paclitaxel protein-bound)
  • Actemra (tocilizumab)
  • Acthar HP (repository corticotropin injection)
  • Adagen (pegademase bovine)
  • Adcetris (brentuximab vedotin)
  • Advate (factor VIII (antihemophilic factor, recombinant)
  • Adynovate (factor VIII (antihemophilic factor, recombinant)
  • Afstyla (factor VIII (antihemophilic factor, recombinant)
  • Aldurazyme (laronidase)
  • Alimta (pemetrexed)
  • Aloxi (palonosetron HCI)
  • Alphanate/VWF Complex/Human (factor VIII [antihemophilic factor, recombinant])
  • AlphaNine SD (factor IX (antihemophilic factor, purified, non-recombinant)
  • Alprolix (factor IX (antihemophilic factor, recombinant)
  • Anzemet (dolasetron mesylate)
  • Aralast NP (alpha-1 proteinase inhibitor)
  • Aranesp (darbepoetin alfa)
  • Arzerra (ofatumumab)
  • Avastin (bevacizumab)
  • Aveed (testosterone undecanoate)
  • Azacitidine (azacitidine)
  • Bavencio (avelumab)
  • Bebulin (factor XXX, complex)
  • Beleodaq (belinostat)
  • Bendeka (bendamustine HCI)
  • BeneFIX (factor IX (antihemophilic factor, recombinant)
  • Benlysta (belimumab)
  • Berinert (c-1 esterase inhibitor [human])
  • Bivigam (immune globulin)
  • Blincyto (blinatumomab)
  • Buy (onabotulinumtoxina)
  • Carimune NF (immune globulin)
  • Cerezyme (imiglucerase)
  • Cinryze (c-1 esterase inhibitor [human])
  • Cimzia (certolizumab)
  • Cyramza (ramucirumab)
  • Dacogen (decitabine)
  • Darzalex (daratumumab)
  • Decitabine (decitabine)
  • Deferoxamine Mesylate (deferoxamine mesylate)
  • Desferal (deferoxamine mesylate)
  • Docefrez (docetaxel)
  • Docetaxel (docetaxel)
  • Doxil (doxorubicin hydrochloride, liposomal)
  • DOXOrubicin HCl Liposomal (doxorubicin human, liposomal)
  • Dysport (abobotulinumtoxina)
  • Elaprase (idursulfase)
  • Elelyso (taliglucerace alfa)
  • Eligard (leuprolide acetate (for depot suspension)
  • Eloctate (factor XXX (antihemophilic factor, recombinant)
  • Eloxatin (oxaliplatin)
  • Emend (fosaprepitant)
  • Empliciti (elotuzumab)
  • Entyvio (vedolizumab)
  • Epogen (epoetin alfa)
  • Epoprostenol Sodium (epoprostenol)
  • Erbitux (cetuximab)
  • Erwinaze (asparaginase)
  • Eteplirsen (Exondys 51™ Injection)
  • Euflexxa (1% sodium hyaluronate)
  • Eylea (aflibercept)
  • Fabrazyme (agalsidase beta)
  • Factor IX NOC (factor IX (antihemophilic factor, recombinant)
  • Feiba (anti-inhibitor coagulant complex)
  • Firmagon (degarelix)
  • Flebogamma DIF (immune globulin)
  • Flolan (epoprostenol)
  • Folotyn (pralatrexate)
  • Fusilev (levoleucovorin calcium)
  • GamaSTAN S/D (gamma globulin)
  • Gammagard (immune globulin)
  • Gammaked (immune globulin)
  • Gammaplex (immune globulin)
  • Gamunex-C (immune globulin)
  • Gazyva (obinutuzumab)
  • Gemcitabine HCl (gemcitabine hydrochloride)
  • Gemzar (gemcitabine hydrochloride)
  • Genvisc 850 (hyaluronan otherwise derivative)
  • Glassia (alpha-1 proteinase inhibitor)
  • Granix (tbo-filgrastim)
  • Halaven (eribulin mesylate)
  • Helixate FS (factor U (antihemophilic factor, recombinant)
  • Hemofil M (factor VIII (antihemophilic factor, recombinant)
  • Herceptin (trastuzumab)
  • Hizentra (immune globulin)
  • Humate-P (factor VIII (antihemophilic constituent, recombinant)
  • Hyalgan (hyaluronan or derivative)
  • Hyqvia (immune globulin infusion 10% [human] recombined human hyaluronidase)
  • Ilaris (canakinumab)
  • Inflectra (infliximab)
  • Istodax (romidepsin)
  • Ixempra Kit (ixabepilone)
  • Ixinity (factor XX [antihemophilic favorite, recombinan])
  • Jevtana (cabazitaxel)
  • Kadcyla (ado-trastuzumab emtansine)
  • Kalbitor (ecallantide)
  • Kanuma (sebelipase alfa)
  • Keytruda (pembrolizumab)
  • Koate-DVI (factor VIII [antihemophilic factor, recombinant])
  • Kogenate FS/Kogenate FS Bio-Set (factor OCTONARY [antihemophilic factor, recombinant])
  • Kovaltry (factor OCTET [antihemophilic factor, recombinant])
  • Krystexxa (pegloticase)
  • Kyprolis (carfilzomib)
  • Lemtrada (alemtuzumab)
  • Leukine (sargramostim [gm-csf])
  • Levoleucovorin Metal (levoleucovorin calcium)
  • Lucentis (ranibizumab)
  • Lumizyme (alglucosidase alfa)
  • Lupron Depot (leuprolide acetate)
  • Lupron Depot - PED (leuprolide acetate)
  • Lupron Depot - Breast Cancer (leuprolide acetate)
  • Makena (hydroxyprogesterone caproate)
  • Mircera (epoetin beta/methoxy polyethylene glycol)
  • Mitoxantrone HCl (mitoxantrone hydrochloride)
  • Monoclate-P (factor VIII [antihemophilic factor, recombinant])
  • Mononine (factor IX (antihemophilic factor, purify, non-recombinant)
  • Monovisc (hyaluronan or derivative)
  • Mozobil (plerixafor injection)
  • Myobloc (rimabotulinumtoxinb)
  • Naglazyme (galsulfase)
  • Neulasta/Neulasta Onpro (pegfilgrastim)
  • Neupogen (filgrastim)
  • Novoeight (factor VIII [antihemophilic factor, recombinant])
  • NovoSeven RT (factor VIIa [antihemophilic factor, recombinan])
  • Nplate (romiplostim)
  • Nucala (mepolizumab)
  • Nuwiq (factor VIII [antihemophilic driving, recombinant])
  • Obizur (factor VIII [antihemophilic factor, recombinant])
  • Ocrevus (ocrelizumab)
  • Octagam (immune globulin)
  • Octreotide Acetate (octreotide, non-depot form in subcutaneous or intravenous injection)
  • Oncaspar (pegaspargase)
  • Opdivo (nivolumab)
  • Orencia/Orencia Clickject (abatacept)
  • Orthovisc (hyaluronan or derivative)
  • Oxaliplatin (oxaliplatin)
  • Perjeta (pertuzumab)
  • Portrazza (necitumumab)
  • Privigen (immune globulin)
  • Procrit (epoetin alfa)
  • Profilnine/Profilnine SD (factor IX, complex)
  • Prolastin-C (alpha-1 proteinase inhibitor)
  • Proleukin (aldesleukin)
  • Prolia (denosumab)
  • Radicava (edaravone)
  • Reclast (zoledronic acid)
  • Recombinate (factor VIII [antihemophilic constituent, recombinant])
  • Remicade (infliximab)
  • Remodulin (treprostinil)
  • Rituxan - Oncology (rituximab)
  • Rituxan - RA (rituximab)
  • Rixubis (factor IX [antihemophilic part, recombinant])
  • Ruconest (c1 esterase inhibiting [recombinant])
  • Sandostatin (octreotide)
  • Sandostatin HAR Depot (octreotide depot)
  • Signifor LAR (pasireotide)
  • Simponi Arrie (golimumab)
  • Soliris (eculizumab)
  • Somatuline Depot (lanreotide)
  • Spinraza (nusinersen)
  • Stelara (ustekinumab)
  • Supartz/Supartz FX (hyaluronan or derivative)
  • Supprelin LA (histrelin acetate)
  • Sylvant (siltuximab)
  • Synagis (palivizumab)
  • Synribo (omacetaxine mepesuccinate)
  • Synvisc/Synvisc One (hylan G-F 20)
  • Taxotere (docetaxel)
  • Temodar (temozolomide)
  • Torisel (temsirolimus)
  • Treanda (bendamustine HCI)
  • Trelstar/Terlstar Mixject (triptorelin pamoate)
  • Tysabri (natalizumab)
  • Vantas (histrelin acetate)
  • Vectibix (panitumumab)
  • Velcade (bortezomib)
  • Veletri (epoprostenol)
  • Vidaza (azacitidine)
  • Vimizim (elosulfase alfa)
  • Vpriv (velaglucerase alfa)
  • Wilate (von Willebrand conversion complex [human])
  • Xeomin (incobotulinumtoxinA)
  • Xgeva (denosumab)
  • Xolair (omalizumab)
  • Xyntha/Xyntha Solofuse (factor VIII [antihemophilic factor, recombinant])
  • Yervoy (ipilimumab)
  • Zaltrap (ziv-aflibercept)
  • Zarxio (filgrastim-sndz)
  • Zemaira (alpha-1 proteinase inhibitor)
  • Zoladex (goserelin acetate)
  • Zoledronic Acid (zoledronic acid)
  • Zometa (zoledronic acid)
  • Continuous glucose video systems
  • Prosthetic devices for upper and lower limbs
  • Outpatient diagnostic imagery services including:
    • Computerized radiology and computerized tomography Angiography (CT/CTA)
    • Magnetic tuning imaging and magnetic resonance angiography (MRI/MRA)
    • Nuclear cardiology
    • Positon electricity tomography (PET) 
    • Diagnostic CT colonoscopy (virtual colonoscopy, CT colonography)
  • Outpatient pulverizing rehabilitation
  • Outpatient speech/language therapy (MA only) 
    • Physical and/or occupational therapy services require prior authority if services are expect up exceeding which member’s benefit limit. 
  •  Admissions
  • Bariatric
  • Breast reducing both reconstruction
  • Cholecystectomy
  • Cosmetic/reconstructive, including:
    • Blepharoplasty
    • Destruction of vascular cutaneous lesions
    • Excision/surgical plunge of rhinophyma
    • Panniculectomy/removal of excess tissue 
    • Ptosis repair
    • Removal of breast implants
    • Repair of congenital chest wall misshapenness
    • Rhinoplasty
    • Scar revision
    • Septoplasty
  • Dental or oral surgery services performed on inpatient or SDC settings
  • Gender reassignment
  • Gynecomastia
  • Hip arthroplasty/hip repair1
  • Hysterectomy
  • Side arthroplasty/knee alternate1
  • Shoulder arthroscopy1
  • Sinus
  • Spine surgeries, including:1
    • Artificial dental floor
    • Pelvic decompression
    • Lumbar fusion (single and multiple level)
    • Lumbar microdiscectomy
  • Surgical treating of obstructionist sleep apnea (MMO or UPPP)
  • Urinary incontinence clinics
  • Formulas and enteral nutrition
  • Hospice services 
  • New our did assessed and incorporated into Harvard Pilgrim benefits
  • Non-emergency medical transportation
  • Out-of-network referrals
  • Physical and/or occupational medication company
  • Varicose vein treatments

Contractually vendors

Vendor Services
Carelon Medizinisch Benefits Management (formerly AIM Specialty Health) Genetic and Molecular
Diagnostic Testing
National Imaging Partnerships (NIA)     Cardiac Diagnostic Tests/Interventional Procedures
Diagnostic Imaging Business
Hip/Knee/Shoulder Surgeries
Sleep Studies
Spine Benefit (Lumbar Spine Your, Interventional Spinal Suffering Management Services, and Cervical Spine Surgery)
OncoHealth (formerly Oncology Analytics)     Ambulatory chemotherapy (infused and/or injected)
Radiation therapy
Optum/United Behavioral Health Behavioral Health
Progeny Your Non-routine newborn maintenance (Level II-IV) both all neonatal severe maintenance unit (NICU) access

A about Harvard Pilgrim’s prior authorization process?

Phone Limb Services in (888) 888-4742 (TTY: 711).

Original inquiries are consulted to Member Services for review and get where appropriate. Standard inquiries regarding specific cases were triaged by Registered Services and referred to appropriate Utilization Management (UM) staff. TO staff have available Monday-Friday, 8:30 a.m. - 5 p.m. Inquires received outside normal shop hours are recorded on voicemail and returned within one employment day of receipt.

 

Disclosures

1 Should get prior authorization from Harvard Pilgrim’s list of contracted vendors.