Network Operations and Care Delivery Management
Includes Local Care Unit (LCU) and Primary Care Provider (PCP) roles, credentialing, and care management.
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.
Includes payment methodologies that apply to claims in general.