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
Prior Authorization Forms
Please note: Prior authorization requirements vary by plan. Please contact HPI Provider Services or log in to Access Patient Benefits and review your patient's plan description for a full list of services requiring prior authorization. Prior authorization forms below are only for plans using AchieveHealth™ CMS. Please verify the correct prior authorization vendor prior to submitting forms; unverified prior authorizations wil be returned.
Standard Prior Authorization Request
If your patient's plan requires Prior Authorization for a service or procedure listed below, please complete the Standard Prior Authorization Request form in addition to the applicable form below.
Bariatric Surgery Precert Questions (Mandatory)
Chemotherapy/Cancer Treatment Medication Chemotherapy Support Drugs
Some forms on this page are in PDF format and require Adobe Reader to open.
