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.

• 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 for Commercial members. Members can visit a Walmart or Rite Aid 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.
• 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. Tufts Health Plan 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 refer to our COVID-19 Testing, Treatment, and Vaccine Coding Grid for guidance on CPT/ICD-10 coding.

• Cost sharing: 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. For all other products offered by Harvard Pilgrim in other states, cost share for COVID-19 treatment applies.
• Monoclonal antibody treatment: Harvard Pilgrim covers medically necessary monoclonal antibody treatment in outpatient settings, without prior authorization as per the FDA’s emergency use authorization (EUA) criteria, for the treatment of mild to moderate COVID-19 in adult and pediatric patients with positive COVID-19 test results who are at high risk for progressing to severe COVID-19 and/or hospitalization. Please refer to monoclonal antibody treatment information from the Centers for Medicare and Medicaid Services and Centers for Disease Control for details on limitations of authorized use and instructions for healthcare providers.
• Ivermectin: For Harvard Pilgrim commercial members, dispensing of Ivermectin oral tablets is limited to 20 tablets within 90 days. Ivermectin is not approved by the FDA for the prevention of treatment of COVID-19. Requests to exceed quantity limits will only be approved for FDA-approved indications or those supported by compendia; requests to exceed quantity limitations for experimental or investigational use will be denied.

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

Please refer to our Interim Telemedicine and Telehealth Payment Policy for guidance on telemedicine coverage for our commercial products, and CMS guidelines for Medicare Advantage. We will continue to evaluate market conditions and will inform the network in advance of an end date or any further changes to this interim policy.

For diagnoses and treatments related to COVID-19 or for members suspected of contracting COVID-19:

• Members of Massachusetts plans: Prior authorization requirements will not be required until further notice. Providers are required to notify Harvard Pilgrim of a Member with COVID-19 admitted to a facility within 2 business days of the admission.
• For all other states and Medicare Advantage plans: Prior authorization requirements are in effect and pre-COVID-19 processes should be followed.

• Massachusetts Commercial Products: In accordance with Massachusetts Division of Insurance Bulletin 2021-15, and until February 15, 2022 (unless otherwise extended by state orders), prior authorization is being waived for scheduled surgeries, behavioral health and non-behavioral health admissions at acute care, mental health hospitals and post-acute care facilities. This applies to COVID-19 and non-COVID-19 related services, including all inpatient treatment. In cases where prior authorization is waived, acute care and mental health facilities are expected to notify Harvard Pilgrim about any inpatient admissions within 2 business days of the admission and to provide updates a minimum of every 5 days to support discharge planning.
• ME Medicare Advantage: Effective for dates of service on or after Aug. 31, 2021 and until further notice, Harvard Pilgrim is waiving prior authorization requirements for transfers from acute care hospitals to post-acute care at non-hospital locations. Notification is required within 2 business days.
• For all other states and products: Prior authorization requirements apply and pre-COVID processes should be followed.

Concurrent review requirements are reinstated for all inpatient treatment (including inpatient hospice services), including behavioral health admissions at acute care hospitals or mental health hospitals. Pre-COVID processes should be followed.

For Medicare Advantage, please be aware that  CMS has extended the suspension of the sequestration payment reduction through Dec. 31, 2021. Consistent with this CMS requirement, Harvard Pilgrim Health Care suspended the reimbursement reductions for Medicare Advantage hospital rates and professional rates for acute care hospitals, clinicians, physicians and PCPs, and is processing claims accordingly.

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.