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

November 2015

Reminder: Referral Procedure Change for Massachusetts Providers

As you are aware, for dates of service effective January 1, 2016 and beyond, Harvard Pilgrim is modifying our current referral procedures to better support coordination of care among Massachusetts providers. This article provides an outline of some key changes and a few important reminders about the referral process.

Procedure change
Please keep the following in mind when making referrals:

  • Massachusetts primary care physicians (PCPs) must initiate a referral transaction 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.
  • 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.
Reminder for specialists 
As of January 1, 2016, specialists in Massachusetts must validate that a referral transaction has been submitted and approved prior to delivering services as a requirement for a claim to be accepted. In addition, providers in all states are still required to submit the name and National Provider Identifier (NPI) of the referring PCP in Boxes 17 and 17B on claim forms.

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 referrals electronically
Primare care providers can initiate referral requests through a variety of channels: electronically or by phone, mail, or fax. We encourage electronic submission — through HPHConnect (Harvard Pilgrim’s Web-based transaction service), NEHEN, or NEHENNet — for timeliness and efficiency. 

Specialist providers are encouraged to confirm a referral transaction is in place and can use existing electronic channels to obtain verification. 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
Please refer to the September and October issues of Network Matters for more information on the referral procedure change for Massachusetts providers, as well as guidance on how to register for HPHConnect. 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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