As valued partners in the care of our members, providers have the option to appeal a coverage denial if they disagree with the result of a Point32Health utilization management (UM) decision. Also referred to as a clinical or pre-service appeal, a UM appeal is a formal request for reconsideration of a denial that providers can submit — either verbally or in writing — on behalf of a Harvard Pilgrim Health Care or Tufts Health Plan member.
To assist you with the submission process, we’ve developed a Guide to navigating pre-service clinical appeals that provides an overview of Point32Health’s UM appeals options as well as step-by-step submission instructions, which vary by product. It also includes key contact information, links to important forms and resources, member appeal rights, and other helpful tips for initiating and submitting UM appeals.
As a reminder, UM appeals are different than claims appeals, which address provider reimbursement disputes for services that have already been rendered. Refer to the Provider Claims Appeals flyer in the Provider Training Guides section of our website for detailed information on the payment dispute process.
We appreciate your commitment to providing our members with the most clinically appropriate care and encourage you to keep these resources handy. For additional guidance, please refer to the applicable sections of our Harvard Pilgrim Health Care and Tufts Health Plan Provider Manuals.