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Change in denial process for lack of prior authorization
Act
by Jun 30, 2026
Effective date
Jul 1, 2026
Identified
Jul 18, 2026
Summary
Point32Health is implementing a cascading denial policy effective July 1, 2026 (September 1, 2026 for Harvard Pilgrim Commercial) where any ancillary or supporting services related to a denied prior authorization claim will also be denied, including medications and procedures billed separately. Ambulance services and radiology/lab report readings are excluded, and Maine providers are exempt from this policy.
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What to do
by Jun 30, 2026 · 7 steps
01Billing team must implement the following workflow changes.
02Update billing software to flag and deny all related ancillary services, medications, and procedures when a primary service is denied for lack of prior authorization, untimely authorization, or failure to meet medical necessity criteria.
03Configure system to deny claims billed on separate claim forms that are linked to a denied primary service.
04Ensure exceptions are programmed for ambulance services and radiology/pathology report readings.
05For Maine-contracted providers: maintain current medical necessity review process per Maine statute 24-A MRS §4304 and do NOT apply the cascading denial logic to fully insured Maine members.
06Audit all pending claims with ancillary services to identify potential cascading denials under the new rules.
07Train providers and billing staff on the new denial cascade logic and the importance of obtaining prior authorization BEFORE billing any related services.
If missed: Failure to implement these changes will result in improper claim processing and potential revenue impact from related service denials.
Original notice
Change in denial process for lack of prior authorization
point32health.org · Always check the source before changing claims.
Related changes
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