Health Plans General Provider Appeal Form (non HPHC)
Harvard Pilgrim Provider Appeal Form and Quick Reference Guide
Prior Authorization Forms
Please note: Prior authorization requirements vary by plan. Please contact HPI Provider Services or 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.
Chemotherapy/Cancer Treatment Medication
Chemotherapy Support Drugs
Some forms on this page are in PDF format and require Adobe Reader to open.