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

September 2016

Improvements to the Corrected Claim and Second-Level Appeals Processes

We’re pleased to let you know about some improvements in our corrected claim and second-level appeals submission processes for providers. These enhancements are based on input from our provider partners, and are aimed at improving your experience by increasing efficiency, providing greater transparency, and reducing turnaround times.

The improvements include:

  • The option to submit  — and track — corrected professional claims electronically
  • An extension of the allowed timeframe for second-level appeals
  • Updates to our appeals letters and policies to provide greater clarity

These changes apply for Harvard Pilgrim corrected claims and provider appeals; they do not affect the UBH/Optum claims and provider appeals process.

Submit your corrected claims electronically

Harvard Pilgrim is now accepting corrected claim submissions electronically (ANSI 837P & I). In the past, corrected claims had to be submitted on paper with a review form. Now, you may submit electronic claims corrections via your usual e-channels with the exception of HPHConnect direct data entry (DDE). At this time submitting corrected claims via direct data entry on the HPHConnect portal is not an option.

You still have the option to submit corrected claims on paper, and we’ve made an improvement in that process as well — you no longer need to include a Request for Claim Review form with paper corrected claims. When submitting by paper, please bill with claim frequency type 7. However, we recommend the electronic submission process for its ease of use, quick turnaround time (so you receive reimbursement sooner), and claims tracking capability.

Please keep the following in mind: as claim corrections will be treated as replacement claims going forward, they will follow the standard initial filing limit times (the standard is 90 days from the date of service). For further information on submitting a corrected/replacement claim, please refer to the Replacement Claim Billing policy.

Extended second-level appeal timeframe

Harvard Pilgrim is also extending the allowed timeframe for second-level appeals from 30 days to 90 days from the date of the first appeal decision letter, to provide more time for you to submit your formal written requests and additional supporting documentation. The filing timeframe for first-level appeals remains unchanged (the standard is 90 days from date of the original explanation of payment).

Updated policies

Harvard Pilgrim has updated the following Provider Manual policies to reflect the changes detailed in this article:

Additionally, we have retired the Corrected Claims Appeal policy. If you have any questions on the changes to Harvard Pilgrim’s corrected claim and appeals submission processes, please contact the Provider Service Center at 800-708-4414 and select option #5. To read more about electronic submission and its benefits, visit the E-Transactions section of our provider website.

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Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator