Point32 Infertility Services Prior Authorization Policy (PM) Form

Harvard Pilgrim Health Care a Point32Health company

Referral, Notification, and Authorization-Authorization

Infertility Services Authorization Criteria

Prior authorization is required for selected infertility services including IUI, IVF, embryo transfer, FET, GIFT, ZIFT, ICSI, donor egg procedures, donor sperm/embryos, cryopreservation of sperm, sperm storage/banking, PGD, MESA, and TESE.

Prior authorization is also required for the retrieval, cryopreservation, and storage of eggs or embryos for female members who are not in active treatment for infertility but will be undergoing medical treatment (e.g., chemotherapy, radiation therapy) that is likely to result in infertility.

To be eligible for coverage, the member's plan must include infertility benefits, and the member must meet applicable Medical Review Criteria.

• Current Medical Review Criteria are available on-line in the Medical Management section of Harvard Pilgrim's provider site at www.harvardpilgrim.org. A copy of Harvard Pilgrim's criteria may also be obtained by contacting Harvard Pilgrim's Provider Service Center at 800-708-4414.
• Self-administered prescription drugs including ovulatory injections (e.g., HCG) are covered for members with HPHC prescription drug coverage only when they are in an active, authorized cycle of infertility treatment.

Services

In-network physicians are responsible for contacting Harvard Pilgrim to obtain prior authorization for infertility and/or cryopreservation services.

• For HMO members, services must be performed by Harvard Pilgrim-contracted providers.
• Not all in-network providers are contracted to provide all infertility services (e.g., providers contracted to provide IUI services might not be contracted to provide IVF services).
• Refer to Harvard Pilgrim's Provider Directory for a list of contracted providers.
• POS and PPO members who elect to receive infertility services from non-contracted providers are responsible for contacting Harvard Pilgrim for prior authorization of services.

Action Required

Prior authorization may be requested through one of the following channels.

Electronic

Submit a transaction record with required information using the HPHConnect or NEHEN transaction service.

• Detailed HPHConnect instructions are available at www.harvardpilgrim.org/providers. (Refer to the user guides at HPHConnect/User Guides.)
• For NEHEN instructions, refer to your NEHEN documentation.

Harvard Pilgrim Response: The request pends for receipt of medical information and nurse reviewer evaluation. Evaluation is completed within two business days after receipt of medical information. The final status will be available online.

HARVARD PILGRIM HEALTH CARE-PROVIDER MANUAL 2014

Telephone or Mail

Send a completed IVF Request form to Harvard Pilgrim's Infertility Coordinator.

Infertility Coordinator
Harvard Pilgrim Health Care
1600 Crown Colony Drive
Quincy, MA 02169

Mail:
Fax: 617-509-4266

Information Required

A completed Infertility Services Prior Authorization Request form including the following information should be submitted before Infertility Services are initiated:

• Member's name and Harvard Pilgrim identification number
• PCP's name and National Provider Identifier (NPI)
• Attending provider's name and National Provider Identifier (NPI)
• Diagnosis and clinical information
• IVF facility or specialist requested
• Procedure requested

All requests for services must be submitted with a valid NPI for the requesting and servicing providers.

Authorization Changes

Harvard Pilgrim must be informed when any change to an authorized procedure occurs, (e.g., change in the date of service change to authorized cycles).

Electronic

Edit the existing transaction record or submit a new transaction record, using the HPHConnect or NEHEN transaction service.

Detailed HPHConnect instructions are available at www.harvardpilgrim.org/providers.

(Refer to the user guides at HPHConnect/User Guides.) For NEHEN instructions, refer to your NEHEN documentation.

Fax or Mail

Send changes to the Harvard Pilgrim Infertility Coordinator.

Infertility Coordinator
Harvard Pilgrim Health Care
1600 Crown Colony Drive
Quincy, MA 02169

Mail:
Fax: 617-509-4266

PUBLICATION HISTORY

12/15/11 Minor edits for clarity
01/15/14 Reviewed; added prior authorization information; minor edits for clarity