Back to Insights and Updates for ProvidersFebruary 2024

Oral formula authorization request update

Harvard Pilgrim Health Care Commercial  |  Harvard Pilgrim Stride (HMO) Medicare Advantage

Editor’s note: Point32Health originally communicated that DME providers would be able to request the number of days for which they will provide oral formula when submitting authorizations as of Feb. 22, 2024. We have encountered some system delays and must postpone this capability — we ask that you please continue to request authorization for oral formula as you have previously done and identify the number of units of formula you will dispense over the date span on the authorization. We apologize for any confusion and encourage you to refer to future issues of Insights and Updates for Providers for updates regarding the submission of formula authorization requests.

Point32Health is implementing a change intended to make it easier and more efficient for contracted durable medical equipment (DME) providers to submit prior authorizations for oral enteral formula for Harvard Pilgrim commercial and StrideSM (HMO)/(HMO-POS) Medicare Advantage members.

As of Feb. 22, 2024, DME providers submitting authorizations for oral formula will no longer need to identify the number of units of formula they will dispense over the course of the date span on the authorization. Instead, these providers should request the number of days for which they will provide formula. The number of days will be used as the count qualifier on the authorization, as opposed to the number of units of formula.

We’re always looking for ways to simplify processes for our providers and make it easier for you to do business with us, and we anticipate that this change will deliver a more streamlined experience by eliminating the need for providers to calculate the number of specific units being dispensed over a span of time.

For prior authorization criteria and reimbursement information, please refer to our Harvard Pilgrim Oral Formula and Enteral Nutrition Medical Necessity Guidelines and Durable Medical Equipment Payment Policy.

Audrey Kleinberg,
Director, Provider Relations & Communications

Annmarie Dadoly,
Senior Manager, Provider Communications

Joseph O’Riordan, Susan Panos, Ryan Francis, Stephen Wong,

Kristin Edmonston,
Production Coordinator

Kristina Cicelova,
Graphic Designer