Harvard Pilgrim Health Care
Welcome to the Harvard Pilgrim HealthCare Health Plan page. Here you can download policies and procedures specific to both ordering and rendering providers. These include quick reference guides and information designed to assist you in using RadMD to request and check the status of prior authorizations.
If you have any questions about our programs, please contact your dedicated NIA Provider Relations Manager, April Sabino.
For dates of service beginning June 24, 2019, the following cardiac procedures will require prior authorization for our commercial members: Cardiac Resynchronization Therapy (CRT), Implantable Cardioverter Defibrillator (ICD), Pacemaker Insertion, Transthoracic Echocardiography (TTE), Transesophageal Echocardiography (TEE), Stress Echocardiography, Heart Catheterization. (These procedures began requiring prior authorization for our Medicare Advantage members on Jan. 1, 2019).
Massachusetts Imaging Prior Authorization Form
- Cardiac Frequently Asked Questions
- Cardiac Frequently Asked Questions -Commercial
- Cardiac Quick Reference Guide
- Cardiac Quick Reference Guide –Commercial
- Cardiac Checklist
- Cardiac Provider Training PPT
- Utilization Review Matrix - Medicare-2022 - updated 7/1/2022
- Utilization Review Matrix - Commercial-2022 - updated 7/1/2022
Musculoskeletal Management Program
Please note that CPT Codes 22800-22819 used for reconstructive spinal deformity surgery and the associated instrumentation do not require NIA/HPHC’s prior authorization. NIA will monitor the use of these CTP codes, but prior authorization is not currently required. As long as, the deformity surgery coded does not include CPT codes on NIA/HPHC’s prior authorization list, the case will process in HPHC claims accordingly.
- Spine Surgery Category & Coding Request Overview
- Interventional Pain Management Procedure Prior Authorization Checklist
- Lumbar Spine Surgery Prior Authorization Checklist
- Spine Management and Prior Authorization LCU Letter
- Spine Management and Prior Authorization Quick Reference Guide for Ordering Physicians/Surgeons
- Spine Management and Prior Authorization Inpatient and Outpatient Spine Surgeries Frequently Asked Questions for Providers
- Spine Management and Prior Authorization Article
- Spine Management Provider Training
- Hip, Knee and Shoulder Focused Provider Training
- Interventional Pain Management Checklist
- Spine Surgery Checklist
- Spine Surgery Authorization and Coding Reference Guide
- Hip Knee and Shoulder Authorization and Coding Reference Guide
- Hip Knee and Shoulder Surgery Utilization Review Matrix-2022
- Spine Surgery Utilization Review Matrix-2022
- Interventional Pain Management Utilization Review Matrix-2022
- Sleep Assessment Records Checklist
- Sleep Solution Provider Training PPT
- Sleep Assessment Announcement Letter
Sleep Management Clinical Guidelines
- Clinical Guidelines
- Sleep Study - Attended with HST
- Sleep Study - Unattended
Pain Management Solution Clinical Guidelines
- IPM Clinical Documentation Guide
- Clinical Guidelines (includes Radiology, Spine Surgery and Interventional Pain Management guidelines)
- Harvard Pilgrim HealthCare Hip, Knee and Shoulder Surgery Reference Guide
- RadMD Pain Managment Quick Start Guide - Injection
- RadMD Pain Managment Quick Start Guide - Surgery
- Tip Sheet
- Peer-to-Peer Process
Conservative Treatment Forms
For access to our conservative treatment forms, click here.
RadMD is a user-friendly, real-time tool offered by Magellan Healthcare that provides ordering and rendering providers with instant access to prior authorization requests for specialty procedures. Whether submitting exam requests or checking the status of prior authorization requests, providers will find RadMD to be an efficient, easy-to-navigate resource.
Search for resources by program:
Recorded General Trainings
We have a series of training videos that discuss the components of requesting a prior authorization request. Click here to access these videos.
Recorded RadMD Demos
Need additional help using RadMD? Click here to access a series of RadMD demos that demonstrate how to properly submit a prior authorization request.
NCDs and LCDS will be used when applicable
- Clinical Guidelines
Refer to the Utilization Review Matrix document to view specific codes managed by NIA
Clinical Training Modules
We have a series of clinical training modules that will help you avoid delays and ensure that you have the right information before submitting your prior authorization request. Click here to access them.
Update on COVID-19
Click here to view our recommendations on the use of CT to detect Coronavirus (COVID-19).