Appeal Forms
Health Plans General Provider Appeal Form (non HPHC)
Harvard Pilgrim Provider Appeal Form and Quick Reference Guide
Precertification Forms
Please note: Precertification requirements vary by plan. Please contact HPI Provider Services or Access Patient Benefits and review your patient's plan description for a full list of services requiring precertification. Precertification forms below are only for plans using AchieveHealth® CMS in New England and Halifax. Please verify the correct precertification vendor prior to submitting forms; unverified precertifications will be returned.
AchieveHealth Precertification List
Standard Precertification Request
If your patient's plan requires Precertification for a service or procedure listed below, please complete the Standard Precertification Request form in addition to the applicable form below.
Chemotherapy/Cancer Treatment Medication Chemotherapy Support Drugs
Some forms on this page are in PDF format and require Adobe Reader to open.
