• Claims
    Electronic and paper submissions; claim submission guidelines; and special considerations when submitting Harvard Pilgrim Medicare Advantage claims.
  • Billing Members
    Copayments/coinsurance and maximum out-of-pocket information; billing members; balance billing; provider responsibility for referrals for non-covered services; provider not qualified to furnish the services billed; and patient not entitles to Medicare Benefits.
  • Coordination of Benefits
    COB information and claim submission process.
  • Claims Review and Audit
    Overview on Harvard Pilgrim’s provider claims audit process.
  • Reimbursement Methodology
    Provider reimbursement process; medical review and reimbursement methodology; National Coverage Determinations (NCDs); Local Coverage Determinations (LCDs); provider documentation for medical review; and payment by provider type for Harvard Pilgrim Medicare Advantage covered services.