Harvard Pilgrim Health Care a Point32Health company

Referral, Notification, and Authorization-Authorization

Durable Medical Equipment (DME) 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.

DME Services Requiring Authorization

Harvard Pilgrim requires Prior Authorization for:

• Diabetes Management Systems
• Miscellaneous DME (i.e., HCPCS code or E1399)
• DME obtained from or requested by non-contracted vendors or providers (not applicable for POS or PPO members)

Harvard Pilgrim’s Medical Review Criteria (used to review Prior Authorization requests) is available online in the Medical Management section of Harvard Pilgrim’s provider site at www.harvardpilgrim.org. A copy of current Medical Review Criteria may also be obtained by contacting Harvard Pilgrim’s Provider Service Center at 800-708-4414.

Action Required

When possible, requests for prior authorization for DME should be submitted at least one week prior to the date of service to allow sufficient time to evaluate member eligibility, level of benefits and medical necessity. Authorization may be requested using HPHConnect, NEHEN or by contacting the Referral and Authorization Unit at 800-708-4414.

To obtain DME, the ordering clinician should call the Harvard Pilgrim contracted provider directly. (Refer to Harvard Pilgrim’s Provider Directory for a list of approved DME providers.)

The DME provider is responsible for obtaining authorization when required. (In urgent situations, contracted providers may initiate services ordered outside normal business hours without obtaining prior authorization; the provider is responsible for contacting Harvard Pilgrim on the next business day to request retrospective authorization.)

If a clinician is providing the DME, the clinician is responsible for obtaining authorization. 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/providers. (Refer to the user guides at HPHConnect/User Guides.)
• For NEHEN instructions, refer to your NEHEN documentation.

Please submit required documentation, Clinical notes/written documentation — via HPHConnect Clinical Upload or secure fax (800-232-0816)

Harvard Pilgrim Response

The request pends for receipt of medical information and reviewer evaluation. Evaluation is completed within two business days after receipt of medical information. The final status will be available online and via mail.

HARVARD PILGRIM HEALTH CARE-PROVIDER MANUAL

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Telephone or Mail

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

Mail:
Harvard Pilgrim Health Care Referral and Authorization Unit
1600 Crown Colony Drive
Quincy, MA 02169

Fax: 800-232-0816

Phone: 800-708-4414

Harvard Pilgrim Response

The request pends for receipt of medical information and reviewer evaluation. Evaluation is completed within two business days after receipt of medical information.

The decision will be communicated by fax or telephone within one business day.

Information Required

The following information is required for a DME request:

• Member’s name and Harvard Pilgrim identification number
• PCP’s or ordering specialist’s name and National Provider Identifier (NPI)
• Provider name and NPI
• Hospital name and location (if applicable)
• Diagnosis and clinical information
• Service requested (type of DME)
• Script information
• Expected length of time DME is needed

All requests 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 item occurs, such as a change in the service request or a change in the authorized length of time DME is needed.

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.

Telephone or Mail

Send changes to Harvard Pilgrim's Referral/Authorization Unit.

Mail:
Harvard Pilgrim Health Care Referral and Authorization Unit
1600 Crown Colony Drive
Quincy, MA 02169

Fax: 800-232-0816

Phone: 800-708-4414

HARVARD PILGRIM HEALTH CARE-PROVIDER MANUAL

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Harvard Pilgrim Health Care a Point32Health company

Referral, Notification, and Authorization-Authorization

Urgent Care

A referral is not required for treatment of an acute or chronic illness or injury that is immediate in nature and requires professional attention but is not life threatening when rendered by a Harvard Pilgrim contracted Free Standing Urgent Care Center.

Hospital Services

The following hospital services do not require PCP referral:

• Inpatient admissions. (Notification is required.)
• Observation services.
• Emergency room (ER) care. (Follow-up care must be approved by the PCP.)

PUBLICATION HISTORY

PUBLICATION HISTORY

• 01/01/12
• 02/15/15

01/01/12 removed First Seniority Freedom information from header

removed First Seniority Freedom information from header added sleep therapy equipment information to "DME Services Requiring Authorization" section; added information to "Action Required" section for clarification; added CareCore National (CCN) utilization management information in footnote

1 removed reference to Sleep Studies/Sleep Therapy Authorization policy updated diabetes management device due to change in policy name updated fax numbers; added information to "Electronic" section regarding uploading documents; removed references to sleep DME equipment from the “DME Services Requiring Authorization section” administrative edits for consistency

• 06/15/17
• 10/01/18
• 04/01/20

HARVARD PILGRIM HEALTH CARE-PROVIDER MANUAL

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