Harvard Pilgrim Health Care a Point32Health company

Referral, Notification, and Authorization-Authorization

Non-Participating Provider Authorization

Unless otherwise specified, information in this policy does not apply to members with the Choice or Choice Plus products offered through Passport ConnectSM. For UnitedHealthcare’s related policies/procedures, please go to www.UnitedHealthcareOnline.com or call 800-708-4414.

Medical Necessity Guidelines

Prior authorization from Harvard Pilgrim is required for all elective (non-urgent) HMO member referrals to providers that are non-participating for their product regardless of where the provider is located or where the service is rendered.¹

Harvard Pilgrim authorizes elective referrals to non-participating providers only in limited situations where we determine that medically necessary services are not available within our contracted provider network, or that referral to the non-participating provider is medically necessary to minimize disruption of ongoing care.

Harvard Pilgrim does not authorize referrals to non-contracted providers whose Harvard Pilgrim contract was terminated for significant quality deficiencies or professional review actions.

Current Medical Necessity Guidelines are available on Harvard Pilgrim’s provider site at www.harvardpilgrim.org. A copy of the current Out-of-Network Referral Medical Necessity Guidelines may also be obtained by contacting Harvard Pilgrim’s Provider Service Center at 800-708-4414.

Member in Active Treatment

New enrollees receiving active treatment at the time their Harvard Pilgrim membership becomes effective may be authorized to continue treatment with non-participating providers for a defined transitional period (up to 30 days after enrollment in most situations) as needed to minimize potential disruption of care.

A member receiving active treatment from a provider whose Harvard Pilgrim contract was terminated for reasons other than quality deficiencies may be authorized to continue treatment with the dis-enrolled provider through the acute phase of the illness, or for up to 90 days (whichever is shorter).

Non-Contracted Provider Obligation

When a referral to a non-contracted provider is authorized, the non-contracted provider must agree to:

• Treat the member for an appropriate period of time (to be determined by the Harvard Pilgrim Utilization Management physician in consultation with the member or non-contracted provider as appropriate).
• Share information relevant to the treatment plan with Harvard Pilgrim (in accordance with HIPPA requirements).
• Accept Harvard Pilgrim’s reimbursement, and not charge the member an amount beyond any required copayment.

Action Required

Harvard Pilgrim authorization is required before an HMO member can be referred to a non-participating provider for consultation, second opinion, treatment or follow-up services. Request prior authorization 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/provider. (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 evaluation. Review is completed within two business days after receipt of medical information. The final status will be available online.

Fax or Telephone

Send required information to Harvard Pilgrim’s Referral/Authorization Unit.

Fax: 800-232-0816
Phone: 800-708-4414 and select the option for the Referral/Authorization Unit.

Harvard Pilgrim Response: The request pends for receipt of medical information and evaluation.

Review is completed within two business days after receipt of medical information. The decision will be communicated in writing within one business day.

Information Required

The following information is needed when requesting services from a non-participating provider:

• Name, address and telephone number of non-participating provider
• Non-participating provider federal tax identification number
• Non-participating provider National Provider Identifier (NPI)
• Non-participating provider specialty
• Member’s identification number
• Member’s diagnosis
• Appointment date
• Service(s) requested (e.g., evaluation, second opinion, treatment)
• Clinical information supporting the request

Harvard Pilgrim requires that all requests for services 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, such as a change in the date of service or a change in the authorized type of service (i.e., inpatient or surgical day care).

Electronic

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

Detailed HPHConnect instructions are available at www.harvardpilgrim.org/provider. (Refer to the user guides at HPHConnect/User Guides.)

For NEHEN instructions, refer to your NEHEN documentation.

Fax or Telephone

Send required information to Harvard Pilgrim’s Referral/Authorization Unit.

Fax: 800-232-0816
Phone: 800-708-4414 and select the option for the Referral/Authorization Unit.

PUBLICATION HISTORY

01/01/12
08/15/13removed First Seniority Freedom information from header reviewed; updated "Criteria" section for clarity

1 Members enrolled in POS or PPO products may self-refer to non-contracted providers and assume responsibility for coinsurance, deductibles, and balance bills as described in their Benefit Handbook