Referral/Authorization Quick Reference Guide for ...

1 Referral/Authorization Quick Reference Guide for Commercial Products This is a resource tool for standard HMO, POS, and PPO products; please keep in mind that products may vary by employer group and state. For the Connecticut Open Access HMO product, no referral is required to see a contracted specialist. No guarantee of payment is implied. Use this Guide as a Quick Reference tool, only, as it is not comprehensive. Consult the commercial Provider Manual for specific product and service requirements or call the Provider Service Center at 800-708-4414. KEY. R = referral MRC = Prior Auth Medical Review Criteria PAF = Prior authorization Request Form N = Notification NP = Notification Policy MAPAF = Massachusetts Standard Form for A = authorization AP = authorization Policy Medication Prior authorization SERVICE HMO and In- PPO and Out of Resources Network POS Network POS. Allergy Injections (specialist services) R none MAPAF.

2 Ambulance Transport for select non-emergent transportation A A MRC. PAF. Artificial Cervical Disc Replacement A A National Imaging Associates (NIA) conducts utilization management review. Refer to NIA website ( ) or call NIA at 800-642-7543. Bariatric Surgeries A A MRC. Behavioral Health/Substance Abuse Services A A MRC. AP. Non-Routine Outpatient Services including: o intensive Treatment Programs Contact Harvard Pilgrim Behavioral Health o Partial Hospitalization and Day Treatment Programs Access Center at 888-777-4742. o Electroconvulsive Treatment (ECT). o Psychological and Neuropsychological Assessment o Transcranial Magnetic Stimulation (TMS). o Extended visits (> 45-50 minutes/session). SERVICE HMO and In- PPO and Out of Resources Network POS Network POS. o Treatment involving more than 1 visit /day Non-emergent Inpatient Admissions Ongoing Inpatient care Bone Marrow Transplant/Stem Cell Transplant (Inpatient N N.)

3 Admissions). Breast Surgeries A A MRC. Breast Implant Removal Breast Reconstruction Breast Reduction Surgery (reduction mammoplasty). Inverted Nipple Repair (Other nipple procedures are covered only when they are a medically necessary part of an authorized breast reconstruction procedure, and relevant HPHC Medical Review Criteria are met.). Bronchial Thermoplasty A A MRC. Cardiac diagnostic tests/interventional procedures (select, non-emergent) none none Refer to NIA website ( ) or call NIA at 800-642-7543. Cardiac Rehabilitation (outpatient) none none Cervical Spine Surgery A A Refer to NIA website ( ) or call NIA at 800-642-7543. Chiropractic Services none none Cholecystectomy A A MRC. Cosmetic and Reconstructive Surgeries, selected A A Cosmetic and Reconstructive Procedures Eye MRC. Eye procedures (blepharoplasty, brow ptosis repair, Nasal MRC. blepharoptosis repair) Skin MRC.

4 Nasal procedures (rhinoplasty, septoplasty, rhinophyma Panniculectomy/Removal of treatment) Redundant Tissue MRC. Skin procedures (scar revision, treatment of hemangiomas and port wine stains). SERVICE HMO and In- PPO and Out of Resources Network POS Network POS. Repair of Congenital Chest Deformities (pectus carinatum, pectus excavatum, Poland Syndrome). Cochlear Implants A A MRC. PAF. Dental/Oral Surgery Services MRC. PAF. AP. Diabetes Management System (See DME below) A A MRC. PAF. Dialysis (outpatient) none none Durable Medical Equipment (DME) authorization AP. required for CGM- MRC PAF. Physician's order required for all DME all items provided Sleep equipment- MRC. authorization required for: to HMO Prosthetic Devices -MRC PAF. o Continuous Glucose Monitoring Systems members by o Sleep therapy equipment non-contracted o Prosthetic Devices (upper and lower limbs) vendors/.

5 O Miscellaneous DME ( , HCPCS code E1399 or A9999) providers Early Intervention Services none none Early Maternity Discharge visit none none Emergency Ambulance Air or Ground Transport none none Emergency Dental care (accidental injury) none none Emergency Room Services none none Enteral Formulas A A MRC. PAF. Extended care Facility A A MRC (Skilled Nursing Facility &. Subacute care ). Skilled Nursing Facility & Subacute care MRC (Inpatient Rehabilitation/. Inpatient Rehabilitation/Long-Term Acute care Long-Term Acute care ). PAF. SERVICE HMO and In- PPO and Out of Resources Network POS Network POS. Monitored Anesthesia care for Gastrointestinal Endoscopic Procedures none none Gender Reassignment Surgeries A A MRC. Genetic and Molecular Diagnostic Testing A A AP. Hereditary Breast/Ovarian Cancers Genetic Testing AIM Specialty Health (AIM) manages HPHC's genetic testing authorization program.

6 Refer AIM's website at or by telephone at 855-574-6476. You may also request authorization via HPHC onnect single sign on. Gynecomastia Surgery A A MRC. Hip Surgeries, select A A National Imaging Associates (NIA) conducts utilization management review. Refer to NIA website ( ) or call NIA. at 800-642-7543. Home Health care A A MRC. AP. Hospice care A A MRC. Home Infusion A A MRC. Human Organ Transplant N N. Hysterectomy A A MRC. Immune Globulin A A Medical Drug Program CVS Health NovoLogix conducts utilization management review for select medical drugs. Submit your request to CVS Health . NovoLogix via HPHC onnect single sign on, phone (844-387-1435) or fax (844-851- 0882). See policies and forms here. SERVICE HMO and In- PPO and Out of Resources Network POS Network POS. Implantable Neurostimulators (deep brain stimulators, A A MRC. gastric stimulators, sacral nerve stimulators, spinal cord MRC.)

7 Stimulators, Vagus Nerve stimulators). Infertility Services (MA): A A MRC. PAF. AI AP. IUI. ART Separate authorizations required for PGD. testing and embryo biopsy through AIM. (see Molecular Diagnostics Medical Review Criteria) before submitting IVF. authorization request to HPHC. Infertility Services (CT) A A MRC. PAF. AP. Separate authorizations required for PGD. testing and embryo biopsy through AIM. (see Molecular Diagnostics Medical Review Criteria) before submitting IVF. authorization request to HPHC. Inpatient Consultations none none Inpatient Medical and Surgical Admissions N (for most N (for most Varies by service. Please refer to prior services). services). authorization form criteria authorization authorization at required for required for admissions for admissions for services on services on Harvard Pilgrim's Harvard Pilgrim's Focused Focused Review List Review List (see Prior (see Prior authorization authorization Policy Policy SERVICE HMO and In- PPO and Out of Resources Network POS Network POS.)

8 For more for more information). information). Interventional Spine Pain Management procedures for A A AP. Back Pain including: National Imaging Associates (NIA) conducts Epidural Injections utilization management review. Refer to Facet Joint Injections NIA website ( ) or call NIA. Facet Neurolysis at 800-642-7543. Intravenous Antibiotics for treatment of Lyme Disease A A MRC. Hyaluronate Preparations for Osteoarthritis of the Knee A A Medical Drug Program CVS Health NovoLogix conducts utilization management review for select medical drugs. Submit your request to CVS Health . NovoLogix via HPHC onnect single sign on, phone (844-387-1435) or fax (844-851- 0882). See policies and forms here. Hip/Knee/Shoulder Surgeries (for select surgeries managed by National Imaging A A AP. Associates). National Imaging Associates (NIA) conducts utilization management review. Refer to NIA website( ) or call NIA.

9 At 800-642-7543. Laboratory Tests (outpatient) none none . Low Protein Food (state mandated) none none Lumbar Spine Surgery including: A A MRC. AP. Lumbar Fusion Single and Multiple Level Lumbar Decompression National Imaging Associates (NIA) conducts Lumbar Microdiscectomy utilization management review. Refer to NIA website ( ) or call NIA. at 800-642-7543. SERVICE HMO and In- PPO and Out of Resources Network POS Network POS. Medical Drugs Select A A Medical Drug Program CVS Health NovoLogix conducts utilization management review for select medical drugs. Submit your request to CVS Health . NovoLogix via HPHC onnect single sign on, phone (844-387-1435) or fax (844-851- 0882). See policies and forms here. Medical Transport for all non-emergent transportation including fixed-wing air A A MRC. and ground PAF. neonatal intensive care Notification is required for all non-routine newborn N N NP.

10 care (level ll - lV) admissions on or after date of service 04/15/17. neonatal Well care (inpatient) none none Non-Participating Provider (inpatient/outpatient) Emergent/urgent N N. Non-Participating Provider (inpatient/outpatient) Elective A N (for inpatient MRC. admissions AP. and Focused Review List services). Nutritional Counseling none none Observation Stay none none Obstetric and Gynecologic Services (outpatient) none none Obstetrical Admissions (delivery) none none Obstetrical Admissions (no delivery) N N. Obstructive Sleep Apnea/Obstructive Sleep Disorders Surgeries: A A MRC. Maxillomandibular Advancement (MMA)/Mandibular Advancement (MA). Uvulopalatopharyngoplasty (UPPP). SERVICE HMO and In- PPO and Out of Resources Network POS Network POS. Genioglossus Advancement/Hyoid Suspension Occupational Therapy Initial visit none none PAF. AP. Occupational Therapy Subsequent visits for " visit Limit" Plans N N PAF.