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

May 2014

Video Presentation: ACA and Risk Adjustment

As last month’s issue of Network Matters highlighted, risk adjustment is one of the significant Affordable Care Act (ACA) reforms taking effect this year. The ACA’s risk adjustment program creates a mechanism to protect against insurer risk selection, promote market stability, and encourage competition on the basis of quality and value.

The ACA risk adjustment program measures and compares the relative health status among health plans’ membership by calculating average risk scores. Since the accuracy of these risk scores is dependent on complete and accurate reporting of diagnoses by physicians, risk adjustment creates an opportunity for health plans and providers to review coding practices and identify and correct common coding gaps.

As part of our efforts to increase awareness about risk adjustment and complete and accurate coding, Harvard Pilgrim has developed a brief audiovisual presentation for providers, which is currently available on our provider website.

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Harvard Pilgrim Health Care Institute Receives National Clinical Award

ICD-10 Testing Continues

Spine Management and Prior Authorization: Sign Up for a Webinar

Harvard Pilgrim Enters Connecticut

Video Presentation: ACA and Risk Adjustment


Comprehensive Approach to Disease Management

Prior Authorization Required for Shoulder Arthroscopy

Expanded Coverage: Capsule Endoscopy of the Small Bowel

Expanded Coverage: Stereotactic Body Radiation Therapy

Hetlioz Now Covered with Prior Authorization

Update: Outpatient Rehabilitative Therapies Authorization

Prior Authorization and Quantity Limits for Testosterone Therapy

South Asian Community Organization Hosts Mental Health Symposium

Complex Case Management

Medication-Assisted Treatment for Opioid Abuse


Reminder: Unlisted Billing Guidelines

CMS 1500 (08/05) Form Rejected After June 15

Reminder for EFT Users with Clearinghouses

2014 Update of the Home Care Seasonal Flu Vaccine Fee Schedule

Reminder: CPT Code for Administering Immunizations


Eric H. Schultz,
President and Chief Executive Officer

Richard Weisblatt PhD,
Senior Vice President, Provider Network

Annmarie Dadoly,

Kristin Edmonston,
Production Coordinator