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

February 2017

Provider Manual Update and Balance Billing


Harvard Pilgrim has updated the Collecting Member Payment policy in our commercial online Provider Manual to provide greater clarity regarding the appropriate method of billing for health services.

The updates include language regarding the practice of “balance billing,” which Harvard Pilgrim does not allow. As a reminder, Harvard Pilgrim-contracted providers may not balance bill members for the difference between actual billed charges and their contracted reimbursement rate. Providers may only collect applicable cost-sharing from Harvard Pilgrim members for covered services and may not otherwise charge or bill them, and a member cannot be balance billed for covered services denied because the provider submitted the claim with insufficient information.

In the event that a provider fails to notify Harvard Pilgrim of a service that requires prior authorization or notification, resulting in a payment denial, the member may not be balance billed and is responsible only for his or her applicable copayments and/or coinsurance. A member cannot be billed for a covered service that is not medically necessary or otherwise not covered under the member's plan, unless the member's informed written consent to receive the specific service is obtained in advance. This consent must be in writing and include the member’s acknowledgement that because the specified service is non-covered, the member will be financially responsible for payment. Requiring a member to sign a general waiver and agreement to be financially responsible for any non-covered service is not sufficient to comply with this policy and may be considered an unfair practice under consumer protection laws.

For more information, refer to the updated Collecting Member Payment policy.

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PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

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Editor

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Writer

Kristin Edmonston,
Production Coordinator