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Friday, July 8, 2016

Administrative denial and Clinical denial - patient responsibility

Administrative Denials

An “administrative denial” occurs when authorization or payment for a particular health care benefit or service is denied because Harvard Pilgrim determines:
• The service is not covered under the member’s policy at the time the service is requested or provided
• A covered service is provided without primary care physician (PCP) approval or Harvard Pilgrim notification/authorization  (when required)
• A limited benefit has been exhausted

Member Liability
Members may be held financially liable for the cost of most services denied for administrative reasons. Members may not be held liable for the cost of services provided without required notification when an in-network provider is responsible for notifying Harvard Pilgrim. (Refer to “Failure to Notify” in the Notification Policy.) Explanation codes (EX codes) on the Explanation of Payment (EOP) indicate when a member may be held financially responsible.


Clinical Denials
Prior authorization is required for selected elective (non-urgent) services. A clinical denial occurs when a Harvard Pilgrim UM physician or designee denies authorization (and payment), or ends coverage, for a particular health care service because service specific medical necessity criteria were not met.


Member Liability
Members may be held liable for the cost of services that are denied prospectively. Explanation codes (EX codes) on the Explanation of Payment (EOP) indicate when a member may be held financially responsible. Members may not be held liable for the cost of services provided without required authorization when an in-network provider is responsible for obtaining prior approval. (Refer to “Failure to Notify” in the Notification Policy.)

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