Doctors, Coverage, ID Cards, Care, Costs, HPHConnect, Prescription Drugs, Privacy,
Rights and Responsibilities, Appeals
Does my doctor participate with Harvard Pilgrim?
You can find out if your doctor is part of the Harvard Pilgrim network by calling your doctor or by searching our online directory.
Do I need a PCP?
It depends on the type of plan you have. If you have an HMO or POS plan, you must choose a PCP to ensure coverage. PPO members are not required to choose a PCP or get referrals for specialty care.
What is the role of my PCP?
Your primary care physician (PCP) can provide or arrange for all the health services you need — treating you when you're sick, administering preventive screenings and providing routine checkups and immunizations.
How do I change my PCP?
You can change your PCP by using HPHConnect, our secure online member self-service tool, or by contacting us.
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How do I get information about my plan benefits?
Please refer to your Schedule of Benefits for details on your coverage.
Where can I find a definition of insurance terms (e.g., deductible, coinsurance, copayments, etc.)?
The federal government has provided a Uniform Glossary of Terms*. Please remember that the federal definition of any term is a general definition or description. Always review your Evidence of Coverage for the specific terms and information that apply to your policy.
What is the difference between HMO, PPO and POS?
- Health Maintenance Organizations (HMO)
- Point-of-Service plans (POS)
- Preferred Provider Oganizations (PPO)
With an HMO, you need to choose a primary care physician (PCP) from the Harvard Pilgrim network. You visit your PCP for routine care or when you're sick. If you have to see a specialist, your PCP will give you a referral in order for Harvard Pilgrim to cover the cost of care. Some services do not require a referral. View your Benefit Handbook for more information.
With a POS plan, members choose a PCP, but can receive care from specialists without their PCP's referral. In addition, POS members can visit doctors, hospitals and other providers who do not belong to Harvard Pilgrim's participating provider network. When provided or arranged by a PCP, services are typically covered in full with copayments. Services received without a PCP referral or outside Harvard Pilgrim's participating provider network are subject to deductibles and coinsurance.
With A PPO, members can choose to receive care for covered services from providers and hospitals that belong to Harvard Pilgrim's participating provider network or from those who don't. Outside of Massachusetts, Maine, New Hampshire and Rhode Island, participating providers also include the Private Healthcare Systems network of more than 360,000 providers and 3,500 hospitals across the United States. When provided or arranged by participating providers, services are typically covered in full with copayments. Services received outside of Harvard Pilgrim's participating provider network are subject to deductibles and coinsurance.
(Not all products are available to all members or in all states.)
What is a Best Buy Plan?
Harvard Pilgrim Best Buy plans have many of the same features as traditional HMOs, POS plans and PPOS, but offer lower premiums. That's due in part to additional cost-sharing features like deductibles, coinsurance or higher copayments for certain services.
Am I covered for the shingles vaccine?
Coverage for the Zoster (shingles) vaccine is limited to age 50+.
Am I covered for a screening colonoscopy?
Colonoscopy falls under the list of preventative service and is covered with no Member Cost Sharing when received from a Plan Provider. Colorectal cancer screening includes: colonoscopy, sigmoidoscopy and fecal occult blood test.
Are breast pumps covered?
As part of Federal Health Care Reform (FHCR) Women’s Preventative Coverage, the following breast pumps and related supplies are covered with no cost sharing.(Includes comprehensive lactation support, counseling, and costs of renting breastfeeding equipment).
- A4281 Tubing for breast pump, replacement
- A4282 Adapter for breast pump, replacement
- A4283 Cap for breast pump bottle, replacement
- A4284 Breast shield and splash protector for use with breast pump, replacement
- A4285 Polycarbonate bottle for use with breast pump, replacement
- A4286 Locking ring for breast pump, replacement
- E0602 Breast pump, manual, any type - This is a purchase only item.
- E0603 Breast pump, electric (AC and/or DC), any type
- E0604 Breast pump, hospital grade, electric (AC and/or DC), any type. 3 month Rental
The following items are excluded:
Nursing pads, gel pads, nipple cream, milk storage bags
Am I covered for transgender services?
Harvard Pilgrim includes coverage for gender reassignment surgery and related transgender medical services on many of our fully insured plans. Read our medical review criteria. To see if your plan includes coverage for these services, log in to HPHConnect for Members and refer to “My Plan Documents.”
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When will I receive my ID card?
You should receive your ID card in 7 to 10 business days from the time your enrollment is processed. However, your coverage is effective on the date your employer specifies (or the date our sales department specifies if you are not applying through an employer group). You can order your Harvard Pilgrim ID card through HPHConnect.
Find out what information is on your ID card*.
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What is HPHConnect?
HPHConnect for members is a secure online member account that helps you manage your personal health through a wide variety of tools and resources. When members set up and use their HPHConnect account, they have secure access to personalized information that will help them to improve their health, compare care options, understand their coverage and costs, update information, and reduce paperwork and phone calls. Subscribers and members, 18 years old and older, can access their personal health information and use many decision support tools.
Create an HPHConnect account
Forgot User Name and Password
What browsers are supported by HPHConnect?
To optimize your HPHConnect experience, we recommend using the latest version of these supported browsers:
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|How do I receive care?|
If you have an HMO or POS plan, you must choose a PCP in order to ensure coverage. Call your PCP for an appointment and bring your ID card with you.
PPO members are not required to choose a PCP or get referrals for specialty care. When you need care, make an appointment with a Harvard Pilgrim provider and bring your ID card with you. If you select a provider outside of the Harvard Pilgrim network, you will be required to pay higher out-of-pocket expenses.
What should I do in a medical emergency?
Harvard Pilgrim covers all medical emergencies (e.g., heart attack, stroke, shock, major blood loss, choking, severe head injury, loss of consciousness, seizures or convulsions.) Go to the nearest emergency facility or call 911 or another local emergency number. If you are hospitalized, notify your PCP and Harvard Pilgrim within 48 hours, or as soon as you can.
If the situation is not a medical emergency, you should call your doctor first. For example, if you have trouble breathing after a cold, accidentally stepped on a nail, or have a nagging backache, call your doctor's office, day or night. Your doctor knows you and your medical history and can give you the best medical advice.
What if I need to see a specialist?
For HMO members:
Your PCP will send you to a specialist affiliated with his or her own practice. For example, if you need to visit a cardiologist, your doctor will refer you to someone in a local medical practice or hospital with which he or she is personally affiliated. Individual PCPs and groups of PCPs typically develop strong working relationships with particular specialists. This enables the doctors to collaborate more effectively on their patients' behalf, and helps ensure excellent communication, appropriate choice of treatment and higher-quality care. Your PCP may occasionally make a referral to a physician outside his or her usual network of specialists, but only if the expertise needed to handle your condition is not available from a specialist affiliated with his or her own practice.
For POS and PPO members:
POS members can receive care from specialists without a PCP referral for out-of-network coverage. PPO members are not required to choose a PCP or get referrals for specialty care.
Do I need authorization from Harvard Pilgrim to receive services?
Yes, Harvard Pilgrim requires prior authorizations for some specific items and services.
Am I covered when I'm traveling?
Yes. If you become sick or injured outside of the Harvard Pilgrim service area, Harvard Pilgrim covers any unforeseen care you may need. Examples include: earaches, flu, poisoning, broken bones, medical emergencies and prescription drugs. You may be responsible for paying out-of-pocket expenses. If you paid out-of-pocket, make sure you obtain a detailed copy of your claim in order ensure reimbursement of your expenses. When you return from traveling, you should contact your PCP and Harvard Pilgrim. Please note: Routine or preventive care (i.e.,care that can be delayed until you return from traveling) is not covered.
Are my dependents covered if they are away at school?
Many employer groups cover children over the age of 19 while they are attending school. Your child or stepchild must be enrolled as a full-time student at an accredited educational institution, and be under age 26. Eligibility guidelines vary by employer group, so please check with your employer for details about your plan.
What are my dependents covered for?
If a covered student resides outside of MA, NH and ME, they are covered for emergency services and inpatient services (not including elective procedures.) Harvard Pilgrim must be notified within 48 hours of any inpatient admission. Outpatient services are also covered such as non-routine office visits and examinations, lab and X-ray services, and short-term rehabilitative care. Routine or preventative care is not covered. All the out-of-area benefits are subject to the standard Harvard Pilgrim benefit limitations and copayments. Students should refer to their Schedule or Summary of Benefits for details and any information on out-of-pocket expenses.
How to get care after hours
Either your doctor or a covering participating provider is available to direct your care 24-hours a day. Talk to your doctor to find out what arrangements are available for care after normal business hours. Some doctors may have covering physicians after hours and others may have extended office/clinic hours.
You can also go to a participating urgent care or convenience care center (like MinuteClinic). In a Medical Emergency, you should go to the nearest emergency facility or call 911 or other local emergency number.
Understand the differences between receiving care at urgent care centers, convenience care centers and the ER.
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What are the different out-of-pocket expenses?
Premium: The premium is the monthly cost of your insurance. Most employers pay part of it and deduct the remainder from your paycheck. Your employer determines the percent you are required to pay. If you do not have direct coverage — through an employer — you will usually pay the entire premium. Best Buy Plans generally have the lowest premiums, followed by HMO, POS and PPO Plans.
Copayment: A fixed amount that you pay each time you receive a covered service, such as a doctor's office visit or a covered prescription.
Deductible: A set amount of money that you may be responsible for each year for certain kinds of medical services. Once you have paid the yearly deductible in full, you are covered for those services for the rest of the year. However, you may need to pay copayments or coinsurance.
Coinsurance: A fixed percentage of covered medical charges that you may be responsible for paying. The coinsurance amount will be specified in your Schedule of Benefits or Summary of Benefits. An example of coinsurance could be that your health plan covers 80% of covered medical charges and you are responsible for the remaining 20%.
Login to HPHConnect to view your Schedule or Summary of Benefits for details on your copayment, deductible and coinsurance.
What is an Out of Pocket Maximum?
A limit on the amount of copayments, coinsurance and deductibles that you must pay yearly for covered services. Please refer to your Benefit Handbook and Schedule of Benefits for specific information on the out-of-pocket maximum that applies to your plan.
How can I get a copy of what I paid out in deductible and copayments so I can file my taxes?
This information can be found in your Activity Summary. The Activity Summary reports the amounts applied to your deductible and out of pocket maximum.
What is the difference between the deductible and the out of pocket maximum on my plan?
Your deductible is the set amount you are responsible to pay annually for certain kinds of medical services. Ex. If your deductible is $500 and you have to have a surgery that is $10,000, you will have to pay the first $500 and the insurance will cover the rest
Your out of pocket maximum limits the total amount you pay each calendar year for healthcare including co-pays, deductibles and co-insurance. For example, your Max out-of-pocket is $5,000. If your co-pays and deductibles paid in that year reach up to $5000, you will no longer have to pay any deductible or co-pays. The insurance will cover 100% of the cost of any other medical care you need that year.
What is a Claim?
A claim is a payment request that a provider submits to Harvard Pilgrim for covered services provided to a Harvard Pilgrim member. The claim is the basis for payment by Harvard Pilgrim to the provider for the covered service. A claim may also be submitted to Harvard Pilgrim by a member if the member pays out-of-pocket for covered services and is entitled to reimbursement.
How do I check the status of claim?
You can check the status of a claim through HPHConnect. The claim status page lists details about claims processed during the past 13 months, including the deductible, coinsurance and copayment amounts.
What is an Activity Summary?
An Activity Summary is not a bill. It is a statement that members who are on cost-sharing plans receive after receiving care. It lists services they received, the amount billed by their provider (doctor, hospital or other health care professional), and the amount paid or denied by Harvard Pilgrim. An Activity Summary will include information about any amount that the member is responsible to pay to the provider. Learn more.
Am I covered for routine eye exams?
Coverage for routine eye exams varies according to your specific health plan. Before scheduling an appointment, please refer to Schedule of Benefits for more details on your coverage.
Am I covered for eyeglasses and contact lenses?
Coverage for eyeglasses and contact lenses depends your plan. please refe rto your Schedule of Benefits for more details on your coverage. See vision program discounts.
I received a questionnaire asking me about other insurance. What does it mean?
Harvard Pilgrim generates a questionnaire when we receive a claim that has some indication of an accident. It could be a medical diagnosis or the provider could indicate the injury is accident related. By filling out the questionnaire we can understand the circumstances of the accident in order to determine if there is third party liability. This way we can process claims correctly now as well as any future claims.
Upon receiving a questionnaire for the first time, member must complete the form and return it to Harvard Pilgrim within 60 days, ever if they have no other insurance.
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How does Harvard Pilgrim's prescription drug benefit work?
Harvard Pilgrim primarily offers two types of prescription drug plans — one with a 3-tier benefit and one with a 4-tier benefit. With both types of plans, Tier 1 always has the lowest cost sharing. In most cases, your doctor can prescribe a Tier 1 or Tier 2 drug to effectively treat your condition — as well as save you money. Should your doctor decide that a higher tier drug (3 or 4 depending on your plan) is best for you, Harvard Pilgrim will still cover your medication but with higher cost sharing.
How do I know which Prescription drug program I have?
Refer to your Harvard Pilgrim member ID card. If your card has three price levels for Rx and mail order, you have a 3-tier program. If your card has four price levels for Rx and mail order, you have a 4-tier program.
Does Harvard Pilgrim cover all prescription drugs?
No, there is a small number of drugs that Harvard Pilgrim does not cover or covers with some restrictions. For a complete list of these medications, visit the Pharmacy Program.
What pharmacies can I use?
There are more than 60,000 pharmacies in our network including local, independent pharmacies, major chains and even an online drugstore. To learn if a specific pharmacy is in the Harvard Pilgrim network, search our online directory or by contacting us.
How can I save money on prescriptions?
You can save money on prescriptions by using generic drugs, whenever appropriate. If you're enrolled in a 4-tier drug benefit, Tier 1 costs just $5 and includes many commonly prescribed prescriptions.You can also our Mail Service Program for the convenience of home delivery for maintenance medications (prescriptions for ongoing, chronic conditions).
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|Is my personal and medical information confidential?|
Yes. Harvard Pilgrim is committed to ensuring the privacy and confidentiality of our members' protected health information (PHI). We collect and disclose such information only according to our strict confidentiality policies and federal and state laws designed to maintain privacy, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule.
The HIPAA Privacy Rule took effect on April 14, 2003, and requires Harvard Pilgrim to provide its members with a Notice of Privacy Practices. The Notice explains how we use information about our members and under what conditions we are permitted to share that information with others.
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|Your Rights and Responsibilities|
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 discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage
- Voice complaints or make appeals about Harvard Pilgrim or the care provided
- 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
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A member can file an appeal whenever Harvard Pilgrim denies coverage. This includes either the denial of a health service sought by a Member or the denial of payment for a health service that a Member has received.
Appeals may be filed in person, by mail, by FAX or by telephone at the addresses or telephone numbers listed below.
Harvard Pilgrim Member Appeals:
Harvard Pilgrim Health Care
1600 Crown Colony Drive
Quincy, MA 02169
Tel: (888) 333-4742
FAX: (617) 509-3085
Appeals concerning mental health services can be sent to the following address:
100 E. Penn Square
Philadelphia, PA 19107
When filing an appeal, a member should include the following information:
- Circumstances related to the request, and why Harvard Pilgrim should reverse the decision
- Information that may support the request, such as letters from the member's doctor or specialist
- All related medical records. If possible, please submit all medical records with the initial appeal request
- Copies of bills if the appeal is for coverage already received
Please note: 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. Members in Maine have one year to file their appeal from the date of the denial.
All appeals are reviewed and responded to in accordance with all state, federal and NCQA guidelines.
If you have additional questions about the appeal process, you can refer to the Appeals and Complaints section of your Benefit Handbook or contact Member Services.
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