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

October 2015

Reminder: Referral Procedure Change for Massachusetts Providers

As we announced in last month’s issue of Network Matters, for dates of service effective January 1, 2016 and beyond, Harvard Pilgrim is modifying our current referral procedures to better support coordination of care. This article offers some key points to remember about the policy change, and details on how to initiate referrals electronically.

Procedure change

Please keep the following in mind when making referrals:

  • 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 (usually 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.
  • Prior to delivering services, the specialist, or other servicing provider, should ensure that a referral has been made and approved.
  • 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.

If an HMO claim is received without the required referral, Harvard Pilgrim will deny payment. 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.

Submit your referrals electronically

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.

HPHConnect is Harvard Pilgrim's highly acclaimed Web-based transaction service. In addition to sending and receiving specialty referrals, you can perform the following transactions with HPHConnect: submitting claim batch files (HIPAA 837 Format), finding the status of a claim, verifying patient eligibility, submitting notifications and receiving authorizations. HPHConnect also offers news and reports, including the drug formulary, PCP membership reports, claims reports, and more.

Registering for HPHConnect is simple. Our online instructions walk you through getting started, and our detailed HPHConnect user guides answer questions you may have about the tool.

Or, if you prefer, referrals can 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 information

For more detailed information on the referral process and requirements, please read 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.

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Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

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Production Coordinator