Point32Health requires prior authorization for certain services to ensure our members receive appropriate medically necessary care that is safe and effective and aligned with clinical guidelines. The authorization process involves determination of eligibility, level of benefits at the time of the request, and medical necessity.
To ensure patients receive timely access to services and providers receive appropriate reimbursement, we recommend the following best practices:
- Check member eligibility. Visit our secure provider portals — HPHConnect for Harvard Pilgrim Health Care members or the Tufts Health Plan secure portal for Tufts Health Plan products — to check member benefits and eligibility.
- Review of our medical necessity guidelines. Our medical necessity guidelines, medical drug medical necessity guidelines, and pharmacy policies are available on our provider website and provide information on services requiring prior authorization and clinical criteria. In addition, our Prior Authorization page offers links to these policy pages, information about vendor programs, and additional authorization resources, such as product-based prior authorization grids.
- Submit your request electronically for greater speed and efficiency. We suggest using our secure portals to submit your authorization requests.
- For medical and behavioral health services, utilize HPHConnect for Harvard Pilgrim Health Care members or the Tufts Health Plan secure portal for Tufts Health Plan products. While electronic submission is preferable, we also accept requests by FAX (to the number noted on the medical necessity guidelines). For guidance on submitting your requests, please refer to our secure portal user guides.
- For pharmacy and medical benefit drugs, utilize PromptPA for quick and easy submission. For details on PromptPA and information on alternatives, such as FAX submission, please visit this pharmacy webpage.
- Include appropriate documentation. Refer to the medical necessity guidelines for details on the supporting documentation needed.
- To avoid unnecessary denials, be sure to use the appropriate type 1 NPI (individual) or type 2 NPI (Org/group) in which you or your group is enrolled.