Prior Authorization (PA) Review
Depending on the type of medication and whether any additional information is needed to process the PA request, the review process can take one day, a few days, or longer. Your assigned nirvanaHealth PA contact will guide you through the process if additional information is required. Please contact the Member Services Center at the number listed on the Contact Us page if you have questions about the PA review process or would like to request a printed copy of a PA policy.
Click here for our Prior Authorization Policies
nirvanaHealth offers prescribers a Peer-to-Peer review when an adverse determination has been issued. A Peer-to-Peer review will be conducted between two (2) licensed health care providers to discuss the clinical details of an adverse determination of a product or service. The Peer-to-Peer review is considered part of the initial decision process, not part of the appeals process.
A Peer-to-Peer review can be requested, verbally or in writing, within two weeks following the date of the notice of adverse determination. A request for Peer-to-Peer review beyond the two-week timeframe will be processed as an appeal. A Peer-to-Peer review may be requested for adverse determinations of medical necessity, not administrative denials. A Peer-to-Peer review will not be performed or scheduled if a formal appeal has already been filed.
The clinical reviewer will discuss the adverse determination and any clinical information used to render the determination with the prescriber. Submission of any additional clinical information after an adverse determination is made is considered an initiation of an appeal.
For your convenience in scheduling a Peer-to-Peer review, nirvanaHealth has a Peer-to-Peer request form available here.
Requesting an Appeal
If an unfavorable decision is rendered for a prior authorization, step therapy override, formulary exception, coverage exception, or quantity limit exception, instructions regarding the appeals process will be included in the decision notification. Additional contact information will be provided. Please contact nirvanaHealth Consumer Services at 877-281-1745 (TTY: 711) if you have questions about an appeal.
For an appeal to be processed as urgent, it must meet the legal definition of urgent. Generally, an urgent situation is one in which the health of the member may be in serious jeopardy or, in your opinion, the member may experience pain that cannot be adequately controlled while waiting for the appeal decision. For urgent requests, nirvanaHealth has up to seventy-two (72) hours from the time of receipt to respond with a decision. For non-urgent appeals, nirvanaHealth has up to thirty (30) days from the date of receipt to respond with a decision.
For your convenience, nirvanaHealth has an appeals form available here.
Please send the appeal to the following address:
Attn: Clinical Appeals
136 Turnpike Road,
Southborough, MA 01772
Fax: 508-452-0096 (for standard appeals requests)
508-452-6421 (for urgent appeals requests)