Our award-winning health & disease management programs

Whatever your health concerns, Harvard Pilgrim’s care management programs can help. For example, our specialized nurses offer personal support to help ensure the healthiest pregnancy. We also can help you learn more about and manage specific conditions such as diabetes, asthma and heart health. 

We also support our members living with multiple or complex conditions—such as chronic kidney disease—with care plans customized to address the unique needs of each.   

To learn more about these programs and if you may be eligible to enroll, just login to your secure account to send us a confidential email. Or call us at (866) 750-2068. 

Behavioral Health:  Get the most out of treatment

If you are being treated for a behavioral health issue (mental health, alcohol or substance use disorder), it’s important that your behavioral health provider and primary care physician (PCP) connect and share information about your health and treatment. 

This exchange of treatment information among the health providers who care for you is called Coordination of Care. Coordination of Care is the way that teams of health care providers communicate and work together to ensure that your health care needs are being safely and effectively met.  For example, it helps your care team prevent harmful medicine interactions or reactions.  It also helps them to address multiple health issues with a more comprehensive and informed approach. If you are coping with both depression and high blood pressure, for instance, coordination of care among your providers helps ensure that treatment for one health condition will not interfere with the other.

What you can do right now
Review this Confidential Exchange of Information form and bring it to your next health appointment. With your signature, it gives your care team your permission to share your health information when appropriate to give you the best possible care.   

It’s also important to keep an updated list of all your prescription and over-the-counter medicines, including vitamins and supplements, to share with your health care team.  

Please note that some employers do not offer behavioral health coverage through Harvard Pilgrim.

Affordable Care Act:  new preventive care benefits for TB screening & statins

There are new preventive care benefits available through Federal Health Care Reform (also known as the Affordable Care Act). 

Screening for Latent Tuberculosis Infection (LTBI)
Effective September 1, 2017, certain members may receive screening for latent tuberculosis infection (LTBI) at no cost.  This benefit is for adults with no symptoms of tuberculosis infection but who have an increased risk for tuberculosis infection.  People at increased risk for tuberculosis infection include people who have lived in countries with increased tuberculosis prevalence or have lived in high-risk settings.  Please consult with your clinician to determine if you are at increased risk for tuberculosis infection. 

Preventive Statin Usage for Certain Adults
Effective November 1, 2017, certain members may receive low- to moderate-dose statin medications for the prevention of cardiovascular disease (CVD) at no cost.  This benefit is only available at no cost for members who meet the following criteria: (1) are between the ages of 40 and 75; (2) have one or more CVD risk factors, such as dyslipidemia, diabetes, hypertension or smoking; and (3) have a calculated 10-year risk of a cardiovascular event of 10% or greater.  Your clinician can determine your risk of a cardiovascular event.  Members who have a history of CVD are not eligible to receive statin medications at no cost under this benefit.  

*Important Note:  These changes do not apply to all employers and plans.  “Grandfathered” plans may be exempt from certain provisions.  Please check with your employer to see if the benefits detailed here apply to your particular plan.

Questions about prior authorizations? 

Prior authorization is a process that requires either your provider or you to obtain approval from Harvard Pilgrim before receiving specific items and services. 

Since plan benefits vary, it’s important that you check My Plan Documents for details on what needs prior authorization. 

If you have additional questions about prior authorizations, or if you or your provider wish to request one, please call (800) 708-4414.   

Your rights & responsibilities as a member

Understanding your rights and responsibilities as a Harvard Pilgrim member helps ensure you get the best possible care when you need it. 

As a member of Harvard Pilgrim, it is your right to:

• Receive information about Harvard Pilgrim, its services, its practitioners and providers and your rights and responsibilities
• Be treated with respect in recognition of your values, dignity and right to privacy
• Participate with practitioners in decisions regarding your health care
• Engage in candid discussions of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage
• Voice complaints about Harvard Pilgrim’s services or appeal any denial of benefits
• Make recommendations regarding these rights and responsibilities policies 

And it’s your responsibility to:

• Provide, to the extent possible, information that Harvard Pilgrim and its practitioners and providers need in order to best care for you
• Follow the plans and instructions for care agreed upon with your practitioners
• Understand your health problems and participate in developing mutually agreed upon treatment goals to the degree that you are able

Teens:  Tips on the transition to adult care

At age 18, young adults legally assume full responsibility of their health care information and decisions.  Here’s how you can help with your teen’s transition to adult care.    

Get input from those you trust
Your family pediatrician likely has very useful input on what timing makes sense and the kind of primary care doctor who might best meet your teen’s adult needs. Friends and family are also reliable resources.

Check them out
You can review the options using our Find a Doctor tool. You can filter candidates according to the experience and profile details most important to you and your family—such as languages spoken, gender, areas of special interest—to find the most suitable PCP for your teen.

Prepare for the first visit

• Arrange medical records and insurance information is sent to the new provider.
• Make a list of all current medicines and any allergies.
• Bring a list of questions or concerns to discuss. 

How can we help? 

If you have questions or we can further assist you and your teen with this transition, please call Harvard Pilgrim’s Member Services department at (888) 333-4742. Representatives are available Monday, Tuesday and Thursday 8 a.m. to 6 p.m., Wednesday 10 a.m. to 6 p.m. and Friday 8 a.m. to 5:30 p.m. For TTY service, call 711.

How care & coverage decisions are made (and what to do when you disagree)

In most situations, Harvard Pilgrim relies on your doctor to determine which medical services you need. Plan authorization is required only for a limited number of medications and elective, or nonurgent, services. When we do require authorization, Harvard Pilgrim’s staff members review your benefit plan and clinical information submitted by your doctor. This review ensures the existence of coverage, and allows Harvard Pilgrim to evaluate the clinical appropriateness of requested services and make a coverage determination. This process is called utilization management. 

For certain services, (e.g., behavioral health, diagnostic imaging, sleep studies and sleep therapy equipment and supplies), other companies may provide utilization management services on behalf of Harvard Pilgrim. 

Harvard Pilgrim does not make decisions regarding the hiring, compensation, termination or promotion of clinical reviewers based on the likelihood that they will support the denial of benefits. We also do not, in any way, offer or provide utilization management or care management clinicians and staff or affiliated providers any incentives or compensation designed to restrict coverage for appropriate, medically necessary care or services. In fact, we work closely with our clinicians and staff and your physicians and providers to ensure that everyone is aware of the potential for harm if medically necessary services are
not provided. 

What to do if you disagree…

You can file a complaint about a coverage decision or appeal that decision at any time.  Because contact information varies by plan and region, please be sure to check your Benefit Handbook within My Plan Documents.  You’ll find simple instructions in the “Appeals & Complaints” section of your handbook.