Change in denial process for lack of prior authorization

IMMEDIATE ACTION REQUIRED - By September 1, 2026 (or sooner for non-Harvard Pilgrim products already affected as of July 1, 2026): (1) Billing team must update all claims management systems and denial tracking procedures to implement cascading denial logic—when a primary service is denied for prior authorization issues, flag and automatically deny all associated ancillary and supporting services on the same and separate claims; (2) Update claim submission protocols to emphasize obtaining prior authorization for primary services BEFORE billing any ancillary services (medications, imaging, lab work, etc.); (3) Train all billing, coding, and prior authorization staff on the new denial codes: UMD1254 (Supporting service denied due to no authorization), CARC A1 (Claim/Service denied), and RARC N19 (Procedure code incidental to primary procedure) for Tufts Health Public Plans and Senior Products; (4) Review all pending claims to identify services that may be subject to retroactive denial if the primary service lacks proper authorization; (5) Communicate with providers that ancillary services CANNOT be billed separately to avoid denial cascade; (6) Document exceptions in your system: radiology professional components (modifier 26), anesthesia, ambulance, pathology professional components only, and pre/post services outside the date of service are NOT subject to cascading denials; (7) For Maine-contracted providers: verify that claims for fully insured members with plans issued in Maine continue to follow Maine insurance statute (24-A MRS §4304) medical necessity review and are NOT subject to this new cascading denial process. Failure to obtain prior authorization will result in denial of the primary service AND all related ancillary/supporting services, significantly impacting revenue.