Harvard Pilgrim – Prior Authorization for Select Hip, Knee, and Shoulder Surgeries

September 2017 ~

Effective December 1, Harvard Pilgrim will require prior authorization through National Imaging Associates, Inc. (NIA) for certain non-emergent inpatient and outpatient hip, knee, and shoulder surgeries for commercial members enrolled in our HMO, PPO, and POS products.

Prior authorization through NIA will be required for the following products and services:


  • Revision/conversion hip arthroplasty
  • Total hip arthroplasty/resurfacing
  • Femoroacetabular impingement (FAI) hip surgery (includes CAM/pincher & labral repair)
  • Hip surgery – other (includes synovectomy, loose body removal, debridement, diagnostic hip arthroscopy, and extra-articular arthroscopy knee)

Knee Revision Knee Arthroplasty 

  • Total knee arthroplasty (TKA)
  • Partial-unicompartmental knee arthroplasty (UKA)
  • Knee manipulation under anesthesia (MUA)
  • Knee ligament reconstruction/repair
  • Knee meniscectomy/meniscal repair/meniscal transplant
  • Knee surgery – other (includes synovectomy, loose body removal, diagnostic knee arthroscopy, debridement with or without chondroplasty, lateral release/patellar realignment, articular cartilage restoration)

Shoulder Revision Shoulder Arthroplasty

  • Total/reverse shoulder arthroplasty or resurfacing
  • Partial shoulder arthroplasty/hemiarthroplasty
  • Shoulder rotator cuff repair
  • Shoulder labral repair
  • Frozen shoulder repair/adhesive capsulitis
  • Shoulder surgery – other (includes debridement, manipulation, decompression, tenotomy, tenodesis, synovectomy, claviculectomy, diagnostic shoulder arthroscopy)

According to Harvard Pilgrim, the insurer chose to partner with NIA due to their clinical expertise in musculoskeletal management. As part of this program, any knee, hip, or shoulder surgery prior authorization requirements that Harvard Pilgrim are currently managing directly (including hip and knee arthroplasty) will transition to NIA. Additionally, Harvard Pilgrim says it will re-introduce prior authorization for knee arthroscopy due to practice pattern variability across its markets.

For more information and complete details regarding this change, refer to NIA’s medical review criteria, Harvard Pilgrim’s Hip/Knee/Shoulder Surgeries Prior Authorization Policy, and Harvard Pilgrim’s Prior Authorization policy in the Provider Manual.


Source(s): Harvard Pilgrim;