Out-of-network liability and balance billing
Covered benefits must be received from an in-network provider (plan provider) to be eligible for coverage by the Plan. However, there are specific exceptions to this requirement. Covered benefits from an out-of-network provider (non-plan provider) will be covered if one of the following exceptions applies:
- The service was received in a medical emergency
- The service was for urgently needed sickness or injury care while a member is temporarily traveling outside of the service area
- The service is one of the covered benefits for a verified dependent living outside of the Enrollment area
- No plan provider has the professional expertise needed to provide the required service. In this case, services by a non-plan provider must be authorized in advance by Harvard Pilgrim, unless one of the exceptions above applies; or
If covered benefits are received from a non-plan provider and the reason for the service is because of (1) a medical emergency, (2) urgently needed sickness or injury care, or (3) no plan provider has the professional expertise needed to provide the required service and the service was authorized in advance by Harvard Pilgrim, then the plan will pay the claim and the member will only be responsible for the applicable member cost sharing as listed in the Schedule of Benefits. The member will not be liable for any balance billing.
If covered benefits are received from a non-plan provider by a verified dependent living outside of the enrollment area, the plan will pay the claim up to the allowed Amount. The member will be liable for applicable member cost sharing as listed in the Schedule of Benefits. If the non-plan provider charges any amount in excess of the allowed amount, the member is liable for the excess amount. The plan will not pay any charges above the allowed amount.
If services are received from a non-plan provider and the reason for the service is not one of the exceptions listed above, the member will be liable for the full cost of the services.
Enrollee claim submission
Harvard Pilgrim requires all medical and behavioral health Plan Providers to submit claims directly to Harvard Pilgrim. A member may submit a claim to Harvard Pilgrim for services provided by a medical or behavioral health non-plan provider. Members may also submit a pharmacy claim for plan and non-plan providers. Members must submit a claim form within one year of the date of service, or fill date for prescription drugs. To request payment for services that have been received, please follow the link below to access our claim submission forms.
Grace periods and claims policies during the grace period
Harvard Pilgrim can terminate your coverage if you fall behind in paying your monthly health insurance premium. Enrollees who fail to pay their premium by the due date have a period of time to pay called a “grace period” before their coverage can be terminated. Enrollees who have received an Advance Premium Tax Credit (APTC) and have paid at least one full month’s premium during the benefit year have a grace period of three consecutive months. The grace period starts the first month an enrollee fails to pay their premium. During the grace period, Harvard Pilgrim will provide enrollees with notice of their premium payment delinquency. Enrollees in a grace period can maintain their coverage if they pay all outstanding premiums before the grace period ends. If an enrollee does not pay all outstanding premium owed by the end of the grace period, Harvard Pilgrim must terminate coverage effective the last day of the first month of the grace period.
Harvard Pilgrim must pay for all claims for covered services received during the first month of the grace period for enrollees who are receiving an APTC. While The Centers for Medicare and Medicaid Services (CMS) permits issuers to pend claims for services provided during the second and third months of the grace period, Harvard Pilgrim does not pend claims during this period.
It is Harvard Pilgrim’s policy to pay all provider claims for dates of service during the second and third months of the grace period. Harvard Pilgrim does not pend claims during this period. Any provider payments made for services during the second and/or the third months of the grace period are subject to retraction by Harvard Pilgrim if the enrollee fails to pay premium for those months.
The enrollee will be responsible for claims for covered services received during the second and/or third months of the grace period if payment of all outstanding premiums is not received by the end of the grace period.
Under certain circumstances, Harvard Pilgrim may reverse a previously paid claim for service (“retroactive denial”), through which a member then becomes responsible for payment. To prevent retroactive denials, please be sure to pay your premium on time so your coverage is not terminated due to nonpayment. Also, Harvard Pilgrim only covers members who live in the Harvard Pilgrim enrollment services area. If you move out of our service area and sign up with another insurer, please be sure your claims are submitted to them.
Recoupment of overpayment
Members enrolling through the Maine or New Hampshire Marketplaces who would like to request a refund for an overpayment should call Harvard Pilgrim’s Member Services department at (877) 907-4742. Please allow three weeks for the refund to be processed and payment to be issued.
Medical necessity and prior authorization timeframes and enrollee responsibilities
Prior authorization is a process that requires either your provider or you to obtain approval from Harvard Pilgrim before receiving specific items and services.
Who is responsible for obtaining prior authorizations?
If you have an HMO plan and see an in-network provider (doctor or clinician), the provider is responsible for obtaining prior authorization for select services noted below.
- If you have a POS or PPO product (including Access America) and you see an in-network provider (doctor or clinician) in the Service Area (as defined in your Benefit Handbook), the provider is responsible for obtaining prior authorization for select services noted below.
- If you have a POS or PPO product (including Access America) and your provider is out-of-network for your plan or is an in-network provider outside of the Service Area (as defined in your Benefit Handbook), your provider or you are responsible for obtaining prior authorization.
- In-network (contracted) providers are responsible for obtaining prior authorization from the plan. In the event they fail to do so, the provider is held responsible for any incurred charges with no financial liability to you, the member.
To obtain prior authorization, your provider or you should call (800) 708-4414 for medical services and the Behavioral Health Access Center at (888) 777-4742 for mental health and substance use disorder treatment.
A decision on a request for prior authorization for medical services will typically be made within 72 hours of us receiving the request for urgent cases or 15 days for non-urgent cases.
The specific benefits subject to prior authorization may vary by product and/or employer group. Please reference the appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.
For additional information on our prior authorization requirements, please click on the following links:
Drug exception timeframes and enrollee responsibilities
Request an exception
If you need a medication that Harvard Pilgrim either doesn’t cover or limits, you or your provider can ask for an exception. Drugs are excluded from coverage if they are not listed on your plan’s formulary (prescription drug list). We will grant exceptions only for clinical reasons. If the drug is denied, you have the right to an external review.
Members can start the exception process by logging into our member portal and completing the online exception request process.
Providers can start the exception process by completing one of the formulary exception/prior authorization forms below and faxing it to our pharmacy benefits manager, OptumRx, at 844-403-1029. They can also call OptumRx customer service at 855-258-1561. OptumRx will need a statement from your provider explaining why an exception is medically necessary, including why a covered drug is not as effective as the requested drug. In CT, MA & NH decisions will be made within two days of receiving your provider’s statement, in ME, a decision will be made within 72 hours or two business days (whichever is less) of receipt. For a faster decision, your provider must provide the necessary medical information with the initial request for an exception.
Your provider may request an expedited exception when you could seriously jeopardize your life, health or ability to regain maximum function if there is a delay in treatment, or if you are undergoing a current course of treatment using a non-covered drug. We will notify you of a decision no later than 24 hours after receiving your expedited request.
Your exception request will be considered by pharmacists and other clinicians as appropriate.
View or download forms
- Harvard Pilgrim Medication Request Form (providers not located in MA or NH)
- MA Standard Medication Prior Authorization Form (pdf)
- NH Standard Medication Prior Authorization Form (pdf)
If we deny your request, you may request an external review by an Independent Review Organization (IRO). An IRO review may be requested by a member, member's representative, or prescribing provider by mailing, calling, or faxing the request to the following:
New Hampshire Insurance Department
Attn: External Review Unit
21 South Fruit Street, Suite 14
Concord, NH 03301
Phone: (800) 852-3416
External Review Applications may be faxed to (603) 271–1406, or sent by overnight carrier to the Department’s mailing address.
Link to form: https://www.nh.gov/insurance/consumers/documents/ex_rev_app.pdf
State of Maine
Department of Professional and Financial Regulation
Bureau of Insurance
34 State House Station
Augusta, ME 04333
(207) 624-7475 or (800) 300-5000
Explanation of Benefits (EOB)
Harvard Pilgrim’s EOB is also known as an Activity Summary. You may find more information about Harvard Pilgrim’s activity summaries using the link below.
Coordination of Benefits (COB)
To the extent that a Harvard Pilgrim member also has health benefits coverage provided by another plan, Harvard Pilgrim will coordinate coverage with the other plan to establish payment of services. In order to accurately process your claims, please use this COB Form to provide information for all other health benefits coverage you or your dependents may have
Public Marketplace machine-readable data
Harvard Pilgrim’s Maine and New Hampshire Public Marketplace plan, provider and formulary data is publicly available in a machine-readable JSON format for use by the Centers for Medicare & Medicaid (CMS), software developers or other interested entities. View the URLs to the data.
 A pended claim means that our payment to the service provider for a claim is on hold until the enrollee’s premium payment is received and applied.