Back to Insights and Updates for ProvidersJuly 2025

Prior authorization and claims denials for Maine

Harvard Pilgrim Health Care Commercial

As a reminder to Maine providers serving fully-insured Commercial members residing in Maine, a failure to comply with Harvard Pilgrim Health Care’s prior authorization requirements will result in a retrospective medical necessity review of the services, instead of an outright denial of any claim for which a provider did not obtain an authorization prior to the service being rendered. As indicated in the Dec. 2024 provider newsletter, this change occurred due to Maine legislation, specifically enactment of amendments to M.R.S.A. 24-A sec. §4304 (H.P. 485 – L.D. 796) effective Jan 1. 2025. To reiterate and clarify:

  • If a Maine provider has not secured the required authorization for a non-emergent service or a drug requiring prior authorization for these Maine members, Harvard Pilgrim will pend the claim for medical necessity review and contact the provider to request documentation to support the review. This documentation enables us to complete a thorough medical necessity review and render a determination (approval or denial) on the service. If we do not receive clinical documentation within 45 days of the request, we will conduct the medical necessity review based on the information available.
  • If our review determines that the service fails to meet medical necessity guidelines, the claim will deny as not medically necessary.
  • If the service or drug is approved upon medical necessity review, Harvard Pilgrim Health Care will process the claim and adjudicate it in accordance with our payment policies and the member’s benefits. In accordance with this Maine legislation, effective as of Jan. 1, 2025, Harvard Pilgrim will assess a penalty of up to 15 percent of the provider’s contractually allowed amount for the claim for failure to comply with prior authorization requirements.
  • To ensure that claims are processed appropriately and without delay, please remember to always obtain the required prior authorizations before the service.

For additional information, please refer to the Prior Authorization Policy in the Harvard Pilgrim Provider Manual.