Appeal Forms
Health Plans General Provider Appeal Form (non HPHC)
Harvard Pilgrim Provider Appeal Form and Quick Reference Guide
Request for Network Exception
Network Exception Request Form
Precertification Requests
Precertification vendors and requirements vary by plan. Please call the Provider Services or Precertification phone number on your patient’s member ID card or visit Access Patient Benefits to determine where to send your precertification request and to review your patient's plan description for a full list of services requiring precertification.
Precertification completed by HPI AchieveHealth® CMS
Precertification forms below are only for plans using AchieveHealth CMS in New England and Halifax. Please verify the correct precertification vendor prior to submitting forms; unverified precertifications will be returned.
AchieveHealth Precertification List
Complete a Precertification Request Online
Download a Precertification Request form* (unverified requests may not be processed)
*If your patient's plan requires Precertification for a service or procedure listed below, please complete the Standard Precertification Request form in addition to the applicable form below.
Chemotherapy/Cancer Treatment Medication
Precertification for Molecular Genetic Testing
Effective June 1, 2024, precertification for molecular genetic testing is delegated by HPI to Carelon Medical Benefits Management (Carelon). The Plan requires providers to obtain precertification for molecular genetic testing; the delegation of Utilization Management (UM) to Carelon, a URAC accredited company, is for members of HPI when CMS administers UM. Ordering providers should contact Carelon to request clinical appropriateness review and obtain a precertification before scheduling or performing any genetic testing services. Ordering providers may submit precertification requests online 24/7 at www.providerportal.com or by calling Carelon toll-free at 833-607-1729, Monday through Friday, 8am to 5pm ET. (Please note Cytogenetics/Cytopathology testing CPT codes 88104-88299 should be sent to HPI directly for review.)
Carelon Genetic Testing Resource Site
Carelon Genetic Testing Guidelines
All Other Utilization Management Vendors
Precertification completed by MedWatch
Complete a Precertification Request Online
Precertification completed by Accolade
Complete a Precertification Request Online
Precertification completed by Cigna
Complete a Precertification Request Online
Precertification completed by Quantum
Complete a Precertification Request Online
Precertification completed by UMR
Complete a Precertification Request Online
Precertification completed by Conifer
Call: 877-687-9527
Some forms on this page are in PDF format and require Adobe Reader to open.
