Commonly asked questions

When you have questions about your benefits and coverage with Harvard Pilgrim, we’re here for you!

Member Services frequently asked questions

Coverage questions

  • HMO members: You will need a referral from your PCP, and you must see a participating specialist.
  • POS members: You will need a referral for authorized coverage. If you don’t get a referral or if you choose to go out of network, you will have higher costs.
  • PPO members: If you see a participating specialist, your costs will be lower than if you see a non-participating specialist.

Adults with Harvard Pilgrim plans can get a flu shot at no charge at:

  • Thier PCP/specialist's office
  • CVS MinuteClinics in Massachusetts, Connecticut, New Hampshire and Rhode Island (not covered in other states)
  • Pharmacies that participate in MedImpact (age 19 years and older only)
  • Massachusetts city/town public clinics coordinated through the Massachusetts Department of Public Health and billed to Harvard Pilgrim Health Care by Commonwealth Medicine
  • Public clinics run and billed by New England Nurses (Massachusetts, southern New Hampshire, and parts of Rhode Island)
  • Public clinics run and billed by Harvard Pilgrim contracted Home Health Agencies
  • Your employer. Check with your Human Resources department to see if your company is offering it

Children coverd on Harvard Pilgrim plans can get a flu shot at no charge at:

  • Their pediatrician's office
  • City/town flu clinics in schools or public clinics for children and adults

Always call ahead to confirm schedules and availability, and make sure the provider or clinic accepts Harvard Pilgrim insurance and will submit a claim. Always bring your ID card with you.

Yes. A colonoscopy is an ACA preventive service. It’s covered at no cost to members when received from a provider who is part of your Harvard Pilgrim network.

As part of Federal Health Care Reform (FHCR) Women’s Preventative Coverage, the following breast pumps and related supplies are covered with no cost sharing.

  • A4281 Tubing for breast pump, replacement
  • A4282 Adapter for breast pump, replacement
  • A4283 Cap for breast pump bottle, replacement
  • A4284 Breast shield and splash protector for use with breast pump, replacement
  • A4285 Polycarbonate bottle for use with breast pump, replacement
  • A4286 Locking ring for breast pump, replacement
  • E0602 Breast pump, manual, any type — this is a purchase-only item
  • E0603 Breast pump, electric (AC and/or DC), any type
  • E0604 Breast pump, hospital grade, electric (AC and/or DC), any type, 3-month rental

Your insurance plan also covers comprehensive lactation support, counseling and the costs of renting breastfeeding equipment. The following items are not covered: nursing pads, gel pads, nipple cream and milk storage bags.

Insurance and care questions

Find out by calling your doctor or search our online directory.

Under the Affordable Care Act, also known as the ACA or the PPACA, there are designated services that are considered preventive and must be covered with no cost to members. You receive preventive services whether you are well or sick. They are benchmarks to assess your health, and they determine if you need more specialized care.

See a list of covered preventive services (

As a Harvard Pilgrim member, you are covered for urgent care at retail clinics, urgent care clinics and other convenient options.

Learn about options when you need urgent care

Find a provider

If we receive a claim for a service that indicates a member received care after an accident, we send the member a questionnaire. The completed questionnaire helps us determine if another insurance company should pay because a third party (a person or business) was responsible for the accident. We can then process claims correctly. The questionnaire should be submitted within 60 days of receipt.

Download the questionnaire

Online account questions

A secure online account helps you manage your health plan through a wide variety of resources. You can review claims and authorizations, track your deductible if you have one, use fitness and wellness tools, and more.

Members age 18 and older must create their own individual accounts even if they are on their parent’s plan.

Create a secure online account

Forgot username/password

Plan questions

Check your Schedule of Benefits in  My Plan Documents in your secure online account. This document is specific to your plan and tells you what is covered and what you pay for services.

Every plan is different. Log into your secure online account to find out if your plan offers a reimbursement.

Learn details about how the fitness reimbursement works

Primary care provider questions

It depends on the type of plan you have. If you have an HMO or POS plan, you must choose a PCP. PPO members are not required to choose a PCP, but it’s typically recommended.

You can change your PCP by logging into your secure online account, or calling Member Services at (888) 333-4742.

Don’t see an answer to your question?

Feel free to contact us directly! You can send us a secure message or contact us by phone.

You’ll need to login to send us a secure message. We’ll promptly reply to your message as soon as we can (usually within 1-2 business days).

Send Message

Contact our Member Services department at (888) 333-4742.

Business hours (Eastern time)
Standard plans:
Monday, Tuesday & Thursday: 8 a.m. to 6 p.m.
Wednesday: 10 a.m. to 6 p.m.
Friday: 8 a.m. to 5:30 p.m.
Access America plans:
Monday, Tuesday, Thursday & Friday: 8 a.m. to 8 p.m.
Wednesday: 10 a.m. to 8 p.m.

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