Better understand your plan and how to get the most out of it.
The latest state regulations, and how upcoming changes may affect your coverage:
Massachusetts
Connecticut
Maine
New Hampshire
How we protect your privacy.
Your rights and responsibilities as a member
Understanding your rights and responsibilities as a Harvard Pilgrim member helps ensure you get the best possible care when you need it.
As a member of Harvard Pilgrim, it is your right to:
- Receive information about Harvard Pilgrim, its services, its practitioners and providers, and your rights and responsibilities.
- Be treated with respect, in recognition of your values, dignity and right to privacy.
- Participate with practitioners in decisions regarding your health care.
- Engage in candid discussions of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
- Voice complaints about Harvard Pilgrim’s services or appeal any denial of benefits.
- Make recommendations regarding these rights and responsibilities policies.
And it’s your responsibility to:
- Provide, to the extent possible, information that Harvard Pilgrim and its practitioners and providers need in order to best care for you.
- Follow the plans and instructions for care agreed upon with your practitioners.
- Understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree that you are able.
Please see your benefit handbook for complete details.
How to appeal a coverage decision and request an external review
Appeals
A member, or authorized representative(s) acting on behalf of a member, may request an appeal for any decision made by Harvard Pilgrim to deny coverage for health services. This applies to (a) health services already received (i.e., denied claim); and, (b) requests to authorize coverage for services in advance (i.e., denied preauthorization or prior approval).
A request for an appeal must be submitted within 180 days of the date of service, or within 180 days from the date payment for a service is denied by Harvard Pilgrim. Appeals submitted beyond the 180-day time frame will not be accepted for review.
To process your appeal request, we will need some specific information from you. Here’s what is important to include:
- The circumstances related to your request, and why you feel the decision should be changed.
- Any information that supports your request (such as letters from your doctor or specialist).
- Copies of any bills related to your appeal.
- Any relevant medical records, so that we may assess clinical necessity.
All appeals are reviewed and responded to in accordance with all state and federal laws and National Committee for Quality Assurance (NCQA) guidelines.
Requests for appeals may be submitted to Harvard Pilgrim in person, by mail or by fax to:
Harvard Pilgrim Health Care
Appeals & Grievances Department
1600 Crown Colony Drive
Quincy, MA 02169
Open weekdays from 8:30 a.m. to 5 p.m.
Fax: (617) 509-3085
To request an appeal by phone, call Harvard Pilgrim’s Member Services department at (888) 333-4742 (TTY: 711).
Representatives are available Mondays, Tuesdays and Thursdays from 8 a.m. to 6 p.m.;
Wednesdays from 10 a.m. to 6 p.m.; and Fridays from 8 a.m. to 5:30 p.m.
Appeals concerning behavioral health services must be submitted to:
Harvard Pilgrim Behavioral Health Access Center
c/o United Behavioral Health
Appeals Department
P.O. Box 30512
Salt Lake City, UT 84130-0512
Phone: (888) 777-4742 Fax: (855) 312-1470
If you have additional questions about the appeal process, please refer to the Appeals and Complaints section of your Benefit Handbook or contact Member Services.
Requesting an external review
If we deny your request for an exemption, you may request an external review by an Independent Review Organization (IRO). An IRO review may be requested by a member, member’s representative or prescribing provider by mailing, calling or faxing the request to the following:
New Hampshire:
New Hampshire Insurance Department
Attn: External Review Unit
21 South Fruit Street, Suite 14
Concord, NH 03301
Phone: (800) 852-3416
External review applications may be faxed to (603) 271-1406 or sent by overnight carrier to the mailing address in the previous section.
Maine:
State of Maine
Department of Professional and Financial Regulation
Bureau of Insurance
34 State House Station
Augusta, ME 04333
(207) 624-7475 or (800) 300-5000
Website
Learn more about preventive care services.
Care management programs
Whatever your health concerns, Harvard Pilgrim’s Care Team of registered nurses, clinical social workers and certified health coaches can help you manage your condition, improve your quality of life and support you in reaching your wellness goals through our population health programs and offerings.
Our Care Team offers personalized support. They help members expecting a baby to have the healthiest possible pregnancy. They support members living with multiple or complex conditions, such as chronic kidney disease. They can also help members manage and learn more about specific conditions, such as diabetes, asthma, cancer and heart disease, with care plans customized to address the unique needs of each.
To learn more about these programs and find out if you may be eligible to enroll, log in to your account to send us a confidential email. Or, you can call us at (866) 750-2068.
Care management support is available at no cost to members and is included with Harvard Pilgrim benefits. Our Care Team works as an educational resource to support our members’ health and wellness goals.
At Harvard Pilgrim, our goal is to provide you with detailed plan information to help guide you toward making the very best health care decisions for you and your family. Log in to your account and click on Plan Details and then View My Plan Documents to view, download, save and print benefits and coverage documents — including your benefit handbook.