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

April 2016

Important Referral Reminders for PCPs


As we announced in previous issues of Network Matters, Harvard Pilgrim modified our referral process at the beginning of this year to better support coordination of care. By familiarizing yourself and your office staff with the updated referral process and following the steps listed below, you help provide a more seamless care transition for your Harvard Pilgrim members, ensure that specialty providers have the information they need, and support your patients in receiving their health care services in a timely manner.

Initiating a referral

Please keep the following key points 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 is making the referral within his or her 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 his or her referral affiliation, a referral transaction is necessary.
  • While the current process of submitting the PCP name and National Provider Identifier (NPI) of the referring provider is still required, it is no longer accepted as proof of referral for our Massachusetts providers.
  • Please notify the specialist to whom you are referring the patient that a referral has been made and supply the necessary information (including the transaction number as verification that the referral was entered into Harvard Pilgrim’s system)
  • Retroactive referrals are still allowed, and standing referrals will continue to be accepted and are valid for 364 days.
  • 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.
Submitting your referrals

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. Our provider website includes more information on HPHConnect, including its functionality and how to register.

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

If you have additional questions, please contact the Provider Service Center at 800-708-4414.

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PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator