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

November 2018

New Emergency Room Cost Sharing Structure for New Hampshire Plans

To help reduce emergency room (ER) overuse for the treatment of injuries and illnesses that aren’t severe or life-threatening, Harvard Pilgrim is introducing a new member cost sharing structure for ER visits for our New Hampshire (NH) commercial plan members.

Currently, NH members pay the deductible and copayment for any ER visit. While that still applies for emergent conditions, starting on Jan. 1, 2019, NH plan members treated at an ER for non-emergent conditions are responsible for the deductible and 50% coinsurance after the deductible has been met. This change will apply for most, but not all, NH employer groups; members of commercial NH plans who are affected by this change will receive new ID cards with the updated cost sharing information.

Harvard Pilgrim will not deny ER claims due to this benefit change.

The new ER cost sharing structure applies for non-emergent diagnoses billed in the primary position and is relevant for diagnoses in approximately 25 categories, with the most common examples being:

  • respiratory infections
  • sprains and strains
  • superficial injury; contusion
  • ear conditions
  • physical exam

Please refer to the complete list of diagnosis codes for which the higher ER copay would apply for additional information.

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Harvard Pilgrim Regional Network Meeting: Manchester NH Kickoff Event


Prior Authorization for Cervical Spine Procedures

Medicare Advantage: Cardiac Prior Authorization Program

New Emergency Room Cost Sharing Structure for New Hampshire Plans

Updates on Medical Drugs Obtained Through Specialty Pharmacy

Billing Monitored Anesthesia Care Policy for Screening Colonoscopies for Commercial Members

Billing Diagnosis Codes for Preventive Services

Newly Covered Codes for Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

Updates to Rituxan Medical Review Criteria

Generic Form of Makena Now Covered

Diabetes Prevention and Management Programs and Resources

New Pharmacy Prior Authorizations for 2019

Pharmacy and Therapeutics Committee Meeting Update


Update to Reimbursement Process for Observation to Inpatient Transition

Modifier SA for Reporting on Behalf of Non-Physician Practitioners


Robert Farias,
Senior Vice President, Corporate Network Strategy

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
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