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

December 2015

CMS Requirement: Enrolling as a Participating Medicare Provider

The Centers for Medicare and Medicaid Services (CMS) has published a new rule that will require nearly all commercial and Medicare Advantage providers who prescribe drugs for Medicare patients to enroll — or validly opt out  — of being a participating Medicare provider as soon as possible.

Effective June 1, 2016, Medicare Part D prescription drug benefit plans may not cover drugs prescribed by providers who have not taken the proper steps to enroll or opt out of participating in Medicare. Please note that if you opt out of participating in Medicare, you will not be able to receive reimbursement from traditional Medicare or Harvard Pilgrim’s Medicare Advantage StrideSM (HMO) plans.

Provider enrollment process

You can enroll as a participating Medicare provider for free, electronically or on paper, either fully or for the limited purpose of prescribing Part D drugs. Harvard Pilgrim encourages electronic enrollment for timeliness and efficiency. 

To enroll as a participating Medicare provider electronically, use the PECOS system at go.cms.gov/pecos. For limited enrollment, refer to these step-by-step instructions on the CMS website, or watch this video tutorial. To enroll on paper, complete the paper application for limited enrollment at go.cms.gov/cms855o and submit it to the Medicare Administrative Contractor (MAC) in your geographic area, which can be found on the MAC list at: go.cms.gov/partdmaclist.

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Network Matters Archives

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Harvard Pilgrim Welcomes New Employer Accounts and Products for 2016


PCSK9 Inhibitors: Prior Authorizations and Innovative Contract for Repatha

Pharmacy Updates: 90-day Supplies at Retail and Controlled Substance Limitations

Reminder: Referral Procedure Change for Massachusetts Providers

Reminder: Prior Authorizations for Medicare Advantage via NIA

Administration of Zostavax by Pharmacists

CMS Requirement: Enrolling as a Participating Medicare Provider

Substance Abuse Screening and Referral for Treatment

Reminder: Mandate on Inpatient Care Related to Breast Cancer


Professional Claim Submission Available on HPHConnect

Improvements in Provider Claims Reporting Tools

Urgent Care Network Requirements


Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator