Change in denial process for lack of prior authorization

Effective for dates of service beginning Sept. 1, 2026 for Harvard Pilgrim Health Care Commercial products and July 1, 2026 for all other products, Point32Health is making a change to our claim adjudication process for ancillary and supporting services when they are billed in connection with services that require prior authorization and that authorization is not obtained.

As of the applicable effective dates, failure to obtain the required prior authorization for a procedure or service will result in denial of the procedure and any related ancillary or supporting services billed on the same claim or on separate claims, due to lack of prior authorization.

This includes medications used to support the procedure requiring prior authorization, and also applies to services or procedures for which an authorization request was submitted but denied. 

Please note that ambulance services will be excluded from this updated denial process. 

Our Provider Manuals will be updated prior to the respective effective dates for each line of business to reflect this change.