Harvard Pilgrim Prior Authorization Policies
OncoHealth conducts medical necessity and utilization review for certain oncology medical drugs and radiotherapy codes on behalf of Harvard Pilgrim Health Care.
Coverage Policies are developed to assist in administering health benefits and aid in the determination of medically necessary therapy. Services determined to be unproven or not medically necessary according to the clinical evidence are typically not covered. Coverage Policies are regularly reviewed, updated at least annually, and are subject to change. Other policies and coverage determination guidelines may apply. Federal and state regulatory requirements and member specific benefit plan documents, as applicable, must be reviewed prior to the Coverage Policy and may take precedence. The policies on this site are used for informational purposes only and do not constitute medical advice or dictate how providers should practice medicine. Health care providers are solely responsible for exercising their medical judgement in determining the appropriate treatment of members. Members need to consult their health care provider before making any decisions about medical care.
All policies are the property of OncoHealth. These policies shall not be reproduced, distributed, stored in a retrieval system, or altered from their original form without written permission from OncoHealth.
Medical Drug Review Criteria and Coverage Policies
Radiotherapy Review Criteria and Coverage Policies