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.
- Medical Reimbursement Form (pdf)
- Behavioral Health Claim Form (pdf)
- Pharmacy claim submission form (pdf)
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. The enrollee would be responsible for claims for covered services received during the second and/or third month 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
You may review Harvard Pilgrim’s medical necessity and prior authorization information using the links below.
Drug exception timeframes and enrollee responsibilities
Please use the link below to review information on how you can ask us to cover a drug that is not covered or not fully covered by your plan.
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 (pdf) to provide information for all other health benefits coverage you or your dependents may have.