How we protect your privacy
 

Take the Personal Health Assessment
This confidential tool can be accessed within your password-secure member account
If you’d prefer a print copy, just call us at (888) 333-4742. Please note that your employer may offer their own Personal Health Assessment.
 

Learn about our quality improvement activities and results
 

1099-HC tax info for Massachusetts members
 

Your rights and 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
     

New Estimate My Cost feature
Health care and health insurance can sometimes be confusing. This tool lets you estimate health care costs for Harvard Pilgrim’s network of providers—before you receive services.
 

How care & coverage decisions are made and how to appeal a decision or request an external review
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 with Harvard Pilgrim by contacting:

Harvard Pilgrim Health Care
Appeals and Grievances Department
1600 Crown Colony Drive
Quincy, MA 02169
Phone: (888) 333-4742
Fax: (617) 509-3085

Appeals concerning behavioral health services should be directed to:

Harvard Pilgrim Behavioral Health Access Center
c/o United Behavioral Health
Attn: Appeals Department
P.O. Box 30512
Salt Lake City, UT 84130-0512
Phone: (888) 777-4742
FAX: 855-312-1470

To request an external review
Certain types of appeals are eligible for further review by state independent external review agencies. Contact the office in your state for more information:

Massachusetts Office of Patient Protection  (800) 436-7757

Connecticut Insurance Department (800) 203-3447

Maine Bureau of Insurance  (800) 300-5000

New Hampshire Insurance Department  (800) 852-3416

If your employer is self-insured, your appeal may be eligible for external review to the extent required by applicable federal law. Check with your employer about your company’s specific policies or contact our Member Services department.

Please also be sure to check your Benefit Handbook within My Plan Documents. You’ll find simple instructions in the “Appeals & Complaints” section of your handbook.