COVID-19 Information and Resources

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.

• 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. Harvard Pilgrim continues to offer coverage for at-home tests in addition to the Medicare coverage through December 31, 2022. Our member website includes detailed instructions for members on how to purchase these tests with no upfront out-of-pocket cost at participating in-network pharmacies or how to submit for reimbursement.
• 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.

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.

• 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.

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.