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

July 2015

Reminder: Now Offering GIC POS and HMO Products

On July 1, Harvard Pilgrim and the Group Insurance Commission (GIC) replaced our PPO product with the Independence Plan POS product. As communicated in an April Network Matters article on Harvard Pilgrim’s 2015-2016 GIC offerings, this move supports our joint efforts to foster Centered Care and develop affiliations with Integrated Risk-Bearing Organizations (IRBOs). In addition, we will continue to offer the Primary Choice HMO.

POS Plan: Referral requirements

The Independence Plan POS product emphasizes coordination of care and the importance of the PCP in managing the overall health of our members. All Independence Plan POS members are required to have a PCP, and have a choice between in-network and out-of-network medical services. Referrals are required for in-network coverage. It’s important that GIC Independence Plan POS members — and the clinicians who treat them — ensure that the member’s PCP approves referrals for specialist visits.

In-network coverage and cost sharing (deductibles, copayments, and coinsurance) applies for services obtained directly from the member’s PCP or from other Harvard Pilgrim participating providers with the appropriate referrals, and higher out-of-network cost sharing applies if the member receives care from non-participating providers or from participating providers without a PCP referral. There are certain exceptions where services may be obtained without a referral, such as routine eye exams and gynecological care.

Referrals can be made electronically using the HPHConnect or NEHEN transaction services or by telephone, fax, or mail. Please visit the Referral, Notification, and Authorization page of our online Provider Manual for referral guidelines, and information on how to initiate the referral process.

POS and HMO product information

In-network benefits and cost sharing for the Independence Plan are similar to Primary Choice benefits and cost sharing. Both plans feature a deductible and a three tiered copayment structure for services obtained in the provider network. Copayments for specialist visits, inpatient hospital services, surgical day care, and prescription drugs increased for both products on July 1, along with the per-member and per-family deductible amounts. The member’s ID card includes copayment information. For information regarding specific benefits and/or copayments, use HPHConnect or call the Provider Service Center at 800-708-4414.

For additional product details, please refer to the GIC Primary Choice HMO and GIC Independence Plan POS product pages in Harvard Pilgrim’s online Provider Manual. For provider tiering information, please visit our provider GIC 2015–2016 plan year webpage.

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Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator