Consistent with new Maine regulation, we are changing our claims denial process as it relates to obtaining a prior authorization. Beginning Jan. 1, 2025 for Maine members of Harvard Pilgrim Health Care fully insured Commercial plans only, we will no longer be denying claims from network providers for failure to obtain prior authorization for a service or medical drug requiring prior authorization. Instead, we will be conducting a post-service review.
In the new post-service process, claims will pend for medical necessity review, and Point32Health will contact the provider to request documentation to support the review. This documentation will enable Point32Health to complete a thorough medical necessity review and render a determination (approval or denial) on the service. Please note that 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 the service is approved upon medical necessity review, Point32Health will process the claim and adjudicate it in accordance with our payment policies and the member’s benefits. If our review determines that the service fails to meet medical necessity guidelines, the claim will deny as not medically necessary.
To ensure that claims are processed appropriately and without delay, please remember to always obtain the required prior authorizations before the service.