Beginning December 20, 2013, Harvard Pilgrim will introduce enhancements to our e-channels—HPHConnect, NEHEN, NEHENNet, HTS and CORE SOAP and MIME—that will make it easier for providers to verify member eligibility and request appropriate authorizations for members in limited network products, as well as verify their status in the limited network.
Our limited network products include: Focus Network–MA (HMO), GIC Primary Choice HMO, ElevateHealth, BIDMC Select Tiered Copayment HMO Plan, and BMC Select. These plans offer access to a provider network that is smaller than Harvard Pilgrim’s full provider network. Members have access to network benefits only from the providers in the product’s participating network. If a member of a limited network product seeks care outside the network—other than for emergency room care—Harvard Pilgrim will not provide reimbursement.
The new information available on our e-channels can help ensure that providers are delivering care that is reimbursable and that members aren’t incurring unexpected costs.
New eligibility information
When checking eligibility for members in a limited network product through our e-channels, providers will receive:
- A reminder of their participation status in the limited network and tier level (if participating). This reminder is now available in NEHEN, NEHENNet, HTS and CORE SOAP and MIME, and will come to HPHConnect in 2014.
- A message informing them that the member participates in a limited network plan and reminding them to verify their own participation status, as well as the participation status of any providers to whom they are referring the member, before rendering services. This reminder becomes available on December 20, 2013.
Harvard Pilgrim’s e-channels will also provide improved, more detailed messaging to non-participating clinicians seeking authorizations to provide services for members of Harvard Pilgrim’s limited network products.
For non-emergency services, the provider will receive a message denying the authorization request*, along with an explanation that the provider is excluded from the network in which the member participates.
In these cases, please advise the member to consult Harvard Pilgrim’s product-specific provider directories or call the Member Services number on their ID card to find a network participating provider. In addition, when a denial is issued, Harvard Pilgrim will send members and providers a letter detailing their appeal rights.
* Denials are issued in most cases. However, if the member is between 17-26 years old, the provider will receive notice that the request is pending while it’s determined whether the member is a student and if there is a participating provider who can render the same service.