Harvard Pilgrim Health Care Home
  Learn more.
  Sign up for HPHConnect.
Medical Management
For Your Patient
News Center
Network Matters
Newsletter Archives
Newsletter Registration
Office Support
Provider Manual
Medicare Advantage
Research & Teaching
Resources & Links
Print    Text Size

Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

November 2016

Important Referral Reminders for PCPs and Specialists

As a reminder, when a Harvard Pilgrim member is referred for specialty services, the referring PCP and the specialist delivering care should each verify that the PCP making the referral is the PCP of record listed for the member in Harvard Pilgrim’s system.

The PCP making the referral is responsible for verifying member eligibility and making sure he or she is the member’s PCP of record by one of the following methods:

  • Accessing electronic (HPHConnect or NEHEN) online member eligibility information
  • Reviewing the most current PCP panel report via HPHConnect
  • Calling the Provider Service Center at 800-708-4414

The specialist receiving the referral should verify that the PCP name and National Provider Identifier (NPI) on the referral match the member’s PCP of record by:

  • Accessing electronic (HPHConnect or NEHEN) online member eligibility information
  • Calling the member’s PCP

If the PCP information is not consistent, the claim will be denied.

In some cases a PCP may be automatically assigned during enrollment, particularly when enrolled through a healthcare exchange. The member may not remember this information or realize this occurred and may inadvertently provide you with the name of a different provider as PCP. In the event that an inconsistency is discovered, please instruct the member to call Harvard Pilgrim’s Member Services Department at 888-333-4742 to correct the PCP information. We’ll be happy to assist the member with changing his or her PCP.

Additional referral reminders for PCPs in Massachusetts

If you are a PCP in Massachusetts, please keep the following key points in mind when making referrals:

  • Massachusetts primary care physicians (PCPs) must initiate a referral transaction to Harvard Pilgrim prior to the services being rendered.
  • If the PCP is making the referral within his or her established referral circle with Harvard Pilgrim (usually among specialists in the PCP’s care unit), a referral transaction is not required. However, if a Massachusetts PCP is referring an HMO or POS product member outside of his or her referral affiliation, a referral transaction is necessary.
  • While the current process of submitting the PCP name and NPI of the referring provider is still required, it is no longer accepted as proof of referral for our Massachusetts providers.
  • Please notify the specialist to whom you are referring the patient that a referral has been made and supply the necessary information (including the transaction number as verification that the referral was entered into Harvard Pilgrim’s system)
  • For more detailed information on the referral process and requirements, please read the Referral, Notification, and Authorization section of Harvard Pilgrim’s online Provider Manual.

Submitting your referrals

You can initiate referral requests through a variety of channels: electronically or by phone, mail, or fax. We encourage electronic submission — through HPHConnect or NEHEN, or NEHENNet — for timeliness and efficiency. Our provider website includes more information on HPHConnect, including its functionality and how to register.

If you prefer, referrals can be submitted by fax to 800-232-0816, by phone to 800-708-4414, or by mail to:

Harvard Pilgrim Health Care
Referral and Authorization Unit
1600 Crown Colony Drive
Quincy, MA 02169

If you have additional questions, please contact the Provider Service Center at 800-708-4414.

    Email this article to a colleague   

    Network Matters Archives

    Download printer-friendly version


    Website Redesign: Navigating to the Provider Website

    Mindfulness CME/CNE Program Offered


    Important Referral Reminders for PCPs and Specialists

    Coverage of Treatment for HIV-Associated Lipodystrophy

    Update to Appeals Filing Limit for Medicare Advantage Plans

    Infertility Services Prior Authorization Criteria Updated

    Reminder: Billing for Professional, Technical, and Global Services

    Diagnosing PTSD and Referral for Treatment


    Update: Sleep Studies Payment Policy


    Eric H. Schultz,
    President and Chief Executive Officer

    Robert Farias,
    Vice President, Network Services

    Annmarie Dadoly,

    Joseph O'Riordan,

    Kristin Edmonston,
    Production Coordinator