For dates of service effective January 1, 2016 and beyond, Harvard Pilgrim is modifying our current referral procedures to better support coordination of care. Under this process change, Massachusetts primary care physicians (PCPs) must submit requests for referrals to Harvard Pilgrim prior to the services being rendered.
If the PCP has an established referral circle with Harvard Pilgrim, typically among specialists in the PCP’s care unit, a referral transaction is not required; however, if a Massachusetts PCP is referring an HMO or POS product member outside of their referral affiliation, a referral transaction is necessary.
While the current process of submitting the PCP name and National Provider Identification (NPI) of the referring provider is still required, it will no longer be accepted as proof of referral in Massachusetts as of January 1, 2016.
This change was made in response to requests by Harvard Pilgrim participating PCPs and physician practices as a means to improve the specialty-referral process by better coordinating care and aiding in the management of medical costs. It also reinforces referral circles and retention of patients in health care systems.
Most aspects of Harvard Pilgrim’s referral process are unchanged. The services that require a referral (and exceptions), the process of initiating a referral, and many of the referral rules remain the same. For example, referrals are not required for certain services (such as certain obstetric and gynecological services or chiropractic services), retroactive referrals are still allowed, and standing referrals will continue to be accepted and are valid for 364 days.
If you currently have a standing referral in place for dates of service beyond January 1, 2016, you will need to submit a new referral transaction in order for Harvard Pilgrim to continue to reimburse these services after January 1.
When submitting a referral transaction, the PCP is responsible for noting the number of visits and type of specialty care requested. It’s also important that the specialist, or other servicing provider, ensures that a referral has been made and approved prior to delivering services.
Keep in mind that if an HMO claim is received without the required referral, Harvard Pilgrim will not cover the services. Providers should also be aware that for POS members, when a member seeks services from an in-network specialist who is outside the referral circle affiliation without a referral transaction in place, the member’s cost share will be higher.
Initiating a referral
You can initiate referral requests through a variety of channels: electronically or by phone, mail, or fax. We encourage electronic submission — through HPHConnect or NEHEN, or NEHENNet — for timeliness and efficiency. Detailed HPHConnect user guides are available on our provider website.
Referrals can also be submitted by fax to 800-232-0816, by phone to 800-708-4414, or by mail to:
Harvard Pilgrim Health Care
Referral and Authorization Unit
1600 Crown Colony Drive
Quincy, MA 02169
For more detailed information on the referral process and requirements, please refer to the Referral, Notification, and Authorization section of Harvard Pilgrim’s online Provider Manual. If you have additional questions, please contact the Provider Service Center at 800-708-4414.