Effective for dates of service beginning April 1, 2026 for our Harvard Pilgrim Health Care Commercial members, Point32Health will require prior authorization for elective inpatient medical admissions, including elective oncology admissions for the administration of chemotherapy drugs, and will apply level of care reviews.

Similar to the change we communicated regarding elective inpatient surgical procedures in the January 2025 issue of Insights and Updates for Providers, we will perform level of care reviews using InterQual criteria. These medical necessity reviews will assess whether it’s more appropriate for a given service or drug to be administered in the inpatient setting or an outpatient setting. 

Please keep in mind that in addition to the authorization for the elective inpatient medical admission itself, you’ll need to continue to follow existing processes for any associated drugs or services requiring prior authorization — including the submission of any necessary accompanying clinical documentation. For example, while Point32Health will apply level of care reviews to the planned administration of chemotherapy drugs, the drugs themselves will still be reviewed separately by OncoHealth. 

Harvard Pilgrim’s Commercial Provider Manual will be updated in advance of the April 1 effective date to reflect this change.