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Provider tiering

Welcome, GIC employees.

Commonwealth of Massachusetts Group Insurance Commission

Harvard Pilgrim placed its participating physicians and hospitals into one of two tiers for the Primary Choice plan and one of three tiers for the Independence Plan, based on cost and quality performance.

Using national quality benchmarks, as well as plan medical expense information, we placed participating hospitals and physician groups in Tier 1, Tier 2 or Tier 3. If a physician group didn’t have sufficient data to rank, the affiliated doctors were placed into Tier 2. Important: The Primary Choice network generally includes only Tier 1 and Tier 2 physician groups and hospitals.

Please note:

  • In limited instances, some hospitals may be excluded from the Primary Choice network regardless of the hospital’s tier status. Likewise, some affiliated provider group practices may be excluded regardless of the physician group’s tier status.
  • Due to separate contract arrangements, some Tier 3 hospitals that are excluded from the Primary Choice network may be participating behavioral health facilities.
  • Children’s Hospital (Boston, Mass.) is a Tier 3 hospital for the Independence Plan. It has been included as a participating hospital for the Primary Choice network at Tier 2 because it is a specialized pediatric hospital.

The copayment amount you pay for covered services will depend on the tier that the providers and hospitals are assigned. Providers’ tier assignments may change at any time (e.g., when they change practice affiliations). Providers who work for more than one practice may be in more than one tier; what you pay will depend on the practice location you visit.