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

March 2018

Reminder: Refer Members to Participating Laboratories

Harvard Pilgrim would like to remind you of the importance of using participating laboratory providers for our members.

Members may incur higher out-of-pocket costs when testing is done at laboratories that do not participate in Harvard Pilgrim’s network. Under some of our plans, seeking care from lower-cost laboratory providers can reduce, or even eliminate, member cost share. Conversely, some of our plans do not provide coverage for services provided by non-participating laboratories, in which case the member may be liable for the entire cost of the service. As an additional benefit, many participating laboratories can automatically upload tests results into electronic health records (EHRs), which allows you share results and reports, and helps eliminate duplicate testing and reduces administrative expenses.

Finding a participating lab near you

You can find the complete list of laboratory providers participating in Harvard Pilgrim’s network in our Provider Directory. For Harvard Pilgrim HMO and PPO plans, participating Harvard Pilgrim independent clinical laboratories include:

  • Quest Diagnostics (CT, MA, NH, ME, RI, VT)
  • LabCorp (CT, MA, NH, RI)
    NorDx (NH, ME)

As locations change periodically, please contact the laboratory provider to confirm which locations are closest to your office or most convenient for the member.

Individualized & appropriate testing

When ordering testing, it is important to remember that only tests that are medically necessary and part of a patient’s treatment plan are covered under Harvard Pilgrim’s payment policies.

Orders should be focused on the patient’s individualized diagnosis and treatment plan, and testing should be consistent with accepted industry standards of practice. When choosing a laboratory, here are some red flags that may be indicative of potential policy or legal violations:

  • Laboratory-generated “custom profile” forms: These forms are used to create testing panels with components that are not specific to an individual patient’s diagnosis and treatment plan. Utilization of these forms often results in medically unnecessary testing being billed to Harvard Pilgrim and your patients.
  • Laboratory results: Test that are not specifically ordered are not being performed by the laboratory free of charge; they are billed to Harvard Pilgrim and are potentially very costly to your patients. As an example, unless ordered for a specific clinical purpose, it would not be appropriate for a laboratory to routinely perform definitive (quantitative) testing for all negative presumptive (qualitative) urine drug test results.
  • Waiver/capping of patient costs: The practice of routinely waiving or discounting a patient’s copayment, deductible, or coinsurance obligations may be a violation of federal and/or state laws. Certain criminal and civil statutes prohibit offering, paying, soliciting, or receiving any remuneration (including the waiver of member cost sharing) to encourage a person to purchase any good or service for which payment may be made by a health care program.

For additional questions or further information on potential policy or legal violations, please contact Harvard Pilgrim’s Special Investigations Unit at 877-548-6712.

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Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Senior Vice President, Corporate Network Strategy

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator