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Provider Manual 2019

The online Provider Manual represents the most up-to-date information on Harvard Pilgrim products, programs, policies and procedures. Information found online may differ from your print version. Contact Provider Relations at 1-800-708-4414, if you have questions.

For details on Harvard Pilgrim's Medicare StrideSM (HMO) and StrideSM of New Hampshire (HMO), please see the Stride (HMO) web page and the Medicare Advantage Provider Manual.

Network Operations and Care Delivery Management
Includes Local Care Unit (LCU) and Primary Care Provider (PCP) roles, credentialing, and care management.

Member Care
Includes information on member rights and responsibilities, determining eligibility, and collecting member payment.

Product and Product Administration
Includes information on HPI, Inc. (third party administrator) and a range of products including the Harvard Pilgrim HMO, POS, PPO, national plans and senior plans.

Referral, Notification and Authorization Administrative Policies and Procedures
Includes Harvard Pilgrim's policies and procedures related to referral, notification and authorization.

Requirements for EDI and Online Solutions
Includes the policies and procedures for Harvard Pilgrim's Web-based transaction service, HPHConnect.

Billing and Reimbursement
Includes electronic and paper submissions, account reconciliation, and claim submission guidelines.

Includes administrative and clinical appeals, filing limit appeals, and second level appeals.

Payment Policies
Includes payment methodologies that apply to claims in general.

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Important Information About This Manual
Referral/Authorization Quick Reference Guide
Key Contacts