CommercialPrior AuthHigh impact
Change in denial process for lack of prior authorization
Harvard Pilgrim Health Care·Prior Authorization
Effective date
Jul 1, 2026
We identified it
Jun 20, 2026
Summary
Point32Health is expanding their denial process so that when a primary procedure lacks required prior authorization, they will now also deny all related ancillary and supporting services billed on the same or separate claims. This includes medications used to support the procedure, but excludes ambulance services.
Action Required
Before July 1, 2026: Billing team must update workflows to ensure prior authorization is obtained for ALL procedures requiring it, as failure will now result in denial of the primary procedure AND all related ancillary services, medications, and supporting services. Review all procedures requiring prior auth and create checklists to verify authorization before scheduling. Train staff that even ancillary services on separate claims will be denied if the primary procedure lacks authorization.