CommercialAdministrativeMedium impact
Using the right pathways to resolve coverage and payment disputes
Harvard Pilgrim Health Care·Prior Authorization
We identified it
Jun 20, 2026
Summary
Point32Health has established mandatory internal appeal and dispute processes that providers must use before seeking external resolution. The policy outlines two pathways: Utilization Management (UM) appeals for coverage/authorization disputes and Claims appeals for payment disputes, with specific forms and procedures for each.
Action Required
Immediately: Billing team must use Point32Health's internal appeals process before external escalation. For UM appeals (coverage/authorization denials), follow the provider's guide to pre-service clinical appeals and include all relevant medical records. For claims appeals (payment disputes), complete the Claims Review Form. Update workflow to request peer-to-peer discussions with medical directors for Commercial/Medicaid members before submitting UM appeals. Failure to use internal processes first may result in delays.