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

October 2016

Habilitative Benefit Requirement and Rehabilitative Benefit Changes

Effective January 1, 2017, in support of the Affordable Care Act’s (ACA’s) essential health benefits requirement, Harvard Pilgrim will cover habilitative services and devices for all non-grandfathered, commercial plans offered in the individual and small group markets, both on and off the exchanges in all states.

Habilitative services are health care services that help a person keep, learn, or improve skills and functioning for daily living. These services may include physical (PT), occupational (OT), speech-language pathology (ST), and other services for people with disabilities in a variety of inpatient and outpatient settings.

In addition to this new coverage requirement, Harvard Pilgrim is making changes to our authorization requirements for some rehabilitative services and eligibility information for therapy services.

Habilitative services requirement

Beginning January 1, 2017, members of the Harvard Pilgrim plans to which the ACA’s mandate applies must have the same level of habilitative benefits as they do rehabilitative benefits. For example, if a member’s coverage includes 20 visits per year for rehabilitative services, it will also include 20 visits per year for habilitative services. 

When submitting claims for habilitative services, providers must bill diagnosis codes in the primary position with the GO/GP modifier in the first modifier position, along with the SZ modifier — which was created to identify services as habilitative.

271 eligibility response and authorization changes

Harvard Pilgrim is also making some updates to our 271 eligibility response transactions and authorization requirements regarding rehabilitative and habilitative services. As of January 1, 2017, the 271 eligibility response for PT, OT, and ST services will return a message reporting “REHABILITATIVE” and “HABILITATIVE” whenever the two benefits are applicable; if a member only has rehabilitative benefits, the response will return only the “REHABILITATIVE” message.
Additionally, no authorization will be required for either habilitative or rehabilitative services with benefits based on number of visits per year. However, authorization will continue to be required for rehabilitative services with per-condition benefits. The eligibility response will include a message that reads “REHABILITATIVE PER CONDITION BENEFIT / AUTH REQUIRED” to indicate those PT, OT, and ST benefits for which an authorization will continue to be required.  The total number of visits covered for a member’s habilitative and rehabilitative benefits is also returned in the 271 eligibility response, as well the number of remaining visits the member has covered in their benefit, as of the date of the eligibility response.

For more information, please refer to the Affordable Care Act — Habilitative Services Policy in Harvard Pilgrim’s online Provider Manual. If you have any questions about the eligibility response changes, please contact the Harvard Pilgrim EDI Team at EDI_team@harvardpilgrim.org or call 800-708-4414 and select option 1, then option 3.

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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