Clinical Review Criteria

Harbor Health Plan utilizes nationally recognized, proprietary clinical review criteria, or both when determining medical appropriateness of health care services.  Harbor Health Plan’s proprietary clinical guidelines are based on current clinical principles and processes.  Criteria are developed and/or reviewed with involvement from appropriate practitioners with current knowledge relevant to the criteria under review. Clinical review criteria are reviewed and approved by the Medical Director and formally adopted by the Utilization Management Committee (UMC) for use by Initial Clinical Reviewers.  Approved Clinical Review Criteria are reviewed against current clinical and medical evidence on an annual basis and updated when appropriate.  If new scientific evidence is not available, the UMC will determine if further review of a criterion is necessary.  Associated policies and procedures are also reviewed annually and updated when appropriate.


The application of any criteria is based upon the individual needs of the member, available services in the local  health care delivery system to meet the member’s specific health care needs (examples include availability of highly specialized services, availability of non-acute, skilled services to support the member after discharge), as well as the age of the member, co-morbidities, medical complications, progress of current treatment, the psychosocial situation and the home environment, when applicable.  Only clinicians make certification decisions.  Additional information may be required to support certification decisions.


Practitioners may request a copy of a specific criterion.  The criterion will be distributed by mail, fax, e-mail, in person or by telephone per the practitioner’s request.  The plan will mail the criterion to practitioners who do not have fax, e-mail, or Internet access unless it is requested in person or by telephone.


Harbor Health Plan uses InterQual® clinical guidelines for majority of services, proprietary clinical guidelines include:

·         Botulinum Toxins A and B

·         Genetic Counseling

·         Genetic Testing

·         Home Health Care Services

·         Hospice and Curative Care - Pediatric

·         Hospice Care – Adult

·         Implantable Cardiac Defibrillator

·         Occupational Therapy

·         Physical Therapy

·         Sacral Nerve Stimulator

·         Speech Therapy


To request a copy of a criterion, please contact our Customer Services Team at 844-427-2671.


Affirmative Statement About Incentives

Utilization Management decision making is based only on appropriateness of care and service and existence of coverage.  Harbor Health Plan does not reward practitioners or other individuals for issuing denials of coverage.  Financial incentives for Um decision makers do not encourage decisions that result in underutilization.


Contacting Utilization Management Department

Harbor Health Plan Utilization Management staff are available to membership via toll-free number between normal business hours of 8:30 am and 5:00 pm EST from Monday through Friday at 1-844-427-2671. After-hours calls are answered by Harbor Health Plan’s contracted answering service and will be returned within one business day. Harbor Health Plan uses the 711 Relay Services to communicate with members with hearing or speech difficulties.