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 Process
Please note that precertification vendors and requirements vary by plan.
1. Determine Precertification Requirements. Prior to submitting a precertification request, determine precertification requirements and where to send your request.
Call the Provider Services or Precertification phone number listed on your patient’s member ID card. Refer to the ID card examples to the right.
Or visit Access Patient Benefits.
2. Submit a Request. Submit a precertification request to the appropriate Utilization Management vendor from the options listed below.
Precertification completed by HPI AchieveHealth® Utilization Management
AchieveHealth Precertification List
Complete a Precertification Request Online
To submit a precertification request by fax:
Download a Precertification Request form*
*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
Molecular Genetic Testing, performed by Carelon Medical Benefits Management
Effective June 1, 2024, HPI’s molecular diagnostic testing program is delegated by HPI to Carelon Medical Benefits Management (Carelon). The program reviews for the following services.
- Pharmacogenomics and thrombophilia testing
- Neurogenetic and neuromuscular testing
- Tumor markers
- Hereditary cardiac testing
- Hereditary cancer testing
- Reproductive carrier screening
- Prenatal testing
- Rare disease testing
- Whole exome/genome sequencing
- Please note: Cytogenetics/Cytopathology testing CPT codes 88104-88299 should be submitted to HPI directly for review.
Providers should submit authorization requests through the Carelon portal at www.providerportal.com or by telephone at 833-607-1729.
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.
