Skip to contentSkip to footer
Harvard Pilgrim Health Care
  • Members
  • Employers
  • Brokers
  • Providers
  • Contact Us
  • PROVIDER MENU
    • Prior Authorization
      • Commercial Medical Necessity Guidelines
      • Medical Benefit Drugs: Medical Necessity Guidelines
      • Vendor Programs
    • Medicare Advantage
      • About Our StrideSM (HMO)/(HMO-POS) Medicare Advantage Plans
      • Medicare Advantage Forms
      • Compliance Program
      • Medicare Advantage Medical Necessity Guidelines
      • Provider Manual for Medicare Advantage
    • Billing and Reimbursement
    • Pharmacy
      • Formulary Lookup & Preventive Drug Lists
      • Pharmacy Medical Necessity Guidelines
    • Provider Manual
      • Network Operations & Care Delivery Management
      • Member Care
      • Referral, Notification & Authorization
      • eServices & Online Solutions
      • Billing & Reimbursement
      • Appeals
      • Payment Policies
    • Caring for Your Patient
    • Resource Center
      • Join Our Network
      • Commercial Forms
      • Electronic Tools and HPHConnect
      • Provider Training and Events
    • Learn About Our Products
      • Tiered Network Product Resources
    • Network Medical Management & Quality
      • Quality Initiatives
      • Physician Group Honor Roll
      • LCU Reporting
    • News Center
      • COVID-19 Information and Resources
      • Network Matters
    • COVID-19 Information and Resources
  • Provider Directory
  • Provider Login
Back to News Center

COVID-19 Information and Resources

Jump to

  • COVID-19 Vaccines
  • COVID-19 Testing and Treatment
  • Telemedicine/Telehealth
  • Prior Authorization
  • Additional information

Latest Updates

12.30.22: Removed reference to StrideSM (HMO)/(HMO-POS) Medicare Advantage coverage of free OTC at-home COVID-19 tests, which ends after Dec. 31, 2022.

9.16.22: Removed previously end dated policies including the Temporary COVID-19 Telehealth/Telemedicine Policy; Medicare Advantage Reimbursement; added clarifying information regarding Bivalent boosters

7.1.22: Removed previously end dated policies related to prior authorization and concurrent review; streamlined existing COVID-19 Treatment information; added information regarding Harvard Pilgrim’s new Telehealth/Telemedicine Payment Policy, effective for dates of service on or after September 1, 2022

05.09.22: Additional coverage updates made to over-the-counter COVID-19 testing for Medicare Advantage members


Overview

During the COVID-19 public health emergency (PHE), we have adapted our policies and business operations to support our members in receiving the care, and to aid our provider partners in their efforts to provide patients with safe access to the care, they need. As states lift PHE orders, Harvard Pilgrim Health Care is returning to many pre-pandemic operations and policies. Please see the information below  for details on Harvard Pilgrim’s COVID-19 related practices.

The PHE-related policies outlined below apply to our fully insured, Medicare Advantage, Medicare Enhance, and Medicare Supplement products, unless otherwise noted. Coverage for self-insured groups may vary. For any product not specifically stated within the PHE-related policies outlined below, the pre-pandemic policy applies.

COVID-19 Vaccines

Harvard Pilgrim understands the urgency of getting vaccines administered swiftly and effectively and is committed to supporting providers in this important work.

The federal government has purchased the vaccine and is supplying it to vaccinators. Providers will receive the vaccines from state and/or federal health agencies.

With the recent U.S. Food and Drug Administration (FDA) Emergency Use Authorization (EUA) of bivalent formulations of the COVID-19 booster vaccines, individuals aged 12 and older should only be offered the updated (bivalent) mRNA (Pfizer-BioNTech or Moderna) booster. Refer to the CDC for information on COVID-19 vaccinations, including primary doses and boosters.

Consistent with federal requirements, Harvard Pilgrim is waiving cost-sharing for the administration of COVID-19 vaccines for all fully-insured members enrolled in all Harvard Pilgrim products in all states.

Harvard Pilgrim is not requiring referrals or prior authorizations for the administration of the COVID-19 vaccination, this includes the COVID-19 vaccine being administered by out-of-network (OON) providers during the PHE.

Harvard Pilgrim is reimbursing for administration of the vaccines and associated services. The reimbursement rate includes vaccine administration, public health reporting, and patient outreach, education, and counseling.

While Harvard Pilgrim encourages the use of in-network providers, we will reimburse in- and out-of-network providers for the administration of the vaccine. Please refer to this COVID-19 Testing, Treatment and Vaccine Coding Grid for details for billing information to ensure claims are processed appropriately.

COVID-19 Testing and Treatment

  • Harvard Pilgrim Health Plan will pay 100% of the allowed amount for medically necessary testing (including, but not limited to radiology and lab tests).
  • Harvard Pilgrim covers in-person polymerase chain reaction (PCR), antigen and antibody laboratory testing for COVID-19 consistent with federal and state guidance at no cost to our members. These tests must be medically necessary, as determined by a health care provider, in accordance with current CDC and state public health department guidelines. Providers should not collect a cost share from members.
    • In order to be considered medically necessary, antibody laboratory testing must be necessary to make decisions required to treat a members’ immediate medical condition. For complete information, please refer to the COVID-19 Antibody Test Medical Policy.
  • Harvard Pilgrim Health Care is covering the cost of up to eight OTC, at-home COVID-19 tests per member, per month. Coverage applies only for tests that are approved by or granted emergency use authorization by the FDA, are intended for individualized diagnosis or treatment of COVID-19 (not for resale) and are not for employment purposes. Coverage is outlined below:
    • Commercial members: Members can visit a participating pharmacy and purchase the tests with no upfront costs. Members paying for at-home tests out-of-pocket can also submit the Member Reimbursement Form with copies of their receipt. We will only pay for eligible tests that are purchased on or after January 15, 2022. Please refer to the member COVID-19 Testing and Coverage page for additional information.
    • Medicare Supplement and Medicare Enhanced members: Over-the-counter COVID-19 tests are covered through Medicare. Members can visit a participating Medicare pharmacy location at no upfront cost. Please refer to medicare.gov for complete coverage information.
    • Medicare Advantage members: As of April 4, 2022, anyone with Medicare Part B coverage, including those enrolled in a Medicare Advantage plan are covered under Medicare.
  • COVID-19 PCR tests that are laboratory processed and either conducted in person or at home must be ordered or referred by a provider to be covered benefits. Harvard Pilgrim Health Care will not cover or reimburse for these tests for members when self-ordered, including when using an online self-completed questionnaire.
  • Testing is not covered solely for general workplace health and safety, public health surveillance or for other purposes not primarily intended for a member’s individual COVID-19 diagnosis or treatment. Diagnostic coronavirus testing required as a condition of travel inside or outside of the United States is not covered.
  • Diagnostic testing required by a provider for surgical or other medical procedures is medically necessary and covered, including if pregnant or expectant parents are required to test prior to admittance to a delivery facility.
  • Members are encouraged to use participating providers/laboratories for all COVID-19 testing. However, this policy applies to in-network and out-of-network providers. As always, coverage is only available to health plan members.

Please bill according to the COVID-19 Testing, Treatment, and Vaccine Coding Grid to ensure claims process appropriately.

Harvard Pilgrim covers FDA approved treatments of COVID-19. Members are encouraged to see in-network providers, whenever possible. However, these policies apply to in-network and out-of-network (OON) providers. For members of Massachusetts commercial products, Harvard Pilgrim continues to waive cost share for COVID-19 treatment, including telehealth services related to COVID-19, in accordance with Massachusetts Division of Insurance Bulletin 2021-08.

Please refer to our Medical Policy for COVID-19 Monoclonal Antibody Therapy and COVID-19 Testing, Treatment and Vaccine Coding Grid  for guidance on CPT/ICD-10 coding.

Telemedicine/Telehealth

Please refer to our permanent Commercial Telehealth/Telemedicine Payment Policy, effective for dates of service on or after Sept. 1, 2022.

For dates of service prior to Sept. 1, 2022, refer to the Interim Telemedicine and Telehealth Payment Policy.

Prior Authorization Policies & Procedures

  • Members of Massachusetts plans: Harvard Pilgrim continues to waive prior authorization requirements for for in-network and OON providers when related to a COVID-19 diagnosis in accordance with Massachusetts Division of Insurance Bulletin 2021-08.
  • For all other states and products: Prior authorization requirements apply and pre-COVID processes should be followed.

Additional information

Harvard Pilgrim has adjusted our policies to reimburse certified registered nurse anesthetists (CRNAs) for providing medically appropriate covered services, including Evaluation and Management and Critical Care services.

Additional Resources

  • COVID-19 Testing, Treatment and Vaccine Coding Grid
  • Interim Telemedicine and Telehealth Payment Policy
  • COVID-19 Antibody Test Medical Policy
  • Harvard Pilgrim Aid for Employers, Members & Providers
  • COVID-19 Information for Members
  • COVID-19 Vaccine Confidence Toolkit

Key Contacts

  • Provider Service Center (commercial): 800-708-4414
  • provider_callcenter@point32health.org
  • Medicare Advantage Service Center: 888-609-0692
  • Care Management: 888-888-4742, ext. 31035
  • eBusiness Services: 800-708-4414 (option 1, then 6)
  • provider_ebusiness_services@point32health.org
A Point32Health company

Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. Together, we're delivering ever-better health care experiences to everyone in our diverse communities.

Provider Tools & Resources

  • Electronic Tools & Transactions
  • Quality Initiatives
  • LCU Reporting
  • Medical Directors Meetings
  • Key Contacts

About Us

  • Careers at Point32Health
  • Newsroom
  • Research & Teaching
  • Our Foundation
  • Contact Us
  • Privacy & Disclaimer Statements
  • Machine-Readable Files

Switch Sites

  • For Brokers
  • For Employers
  • For Members

Nondiscrimination

  • Español (Spanish)
  • Português (Portuguese)
  • Kreyòl Ayisyen (French Creole)
  • 繁體中文 (Traditional Chinese)
  • Tiếng Việt (Vietnamese)
  • Русский (Russian)
  • العربية (Arabic)
  • ខ្មែរ (Cambodian)
  • Français (French)
  • Italiano (Italian)
  • 한국어 (Korean)
  • Eλληνικά (Greek)
  • Polski (Polish)
  • हिंदी (Hindi)
  • ગુજરાતી (Gujarati)
  • English (English)
  • ພາສາລາວ (Lao)

ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-888-333-4742 (TTY: 711).

© 2023 Harvard Pilgrim Health Care, Inc. All rights reserved.

Privacy and Disclaimer Statements

  • Facebook
  • LinkedIn
  • YouTube