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Take the Well-being Assessment
This confidential tool can be accessed within your 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 Well-being Assessment.
Learn about our quality improvement activities and results
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
Massachusetts: Expanded behavioral health coverage for children and adolescents
The below coverage applies to all fully insured commercial Massachusetts plans. Most self-insured plans do not provide this coverage. If you are covered under a self-insured plan that includes this coverage, the benefits will be listed in your benefit handbook.
Bulletin 2018-07 from the Massachusetts Division of Insurance and the Executive Office of Health and Human Services Department of Mental Health requires commercial health plans provide coverage of certain child-adolescent mental health services on a non-discriminatory basis for the diagnosis and treatment of mental health disorders which substantially interfere with or substantially limit the functioning and social interactions of the child or adolescent through the age of 18. The bulletin states that “child-adolescent mental health services” shall consist of a range of inpatient, intermediate, and outpatient services that shall permit medically necessary and active and noncustodial treatment for said mental disorders to take place in the least restrictive clinically appropriate setting. This may include the Member’s home or a program in another community-based setting. The services can be provided to the child, the child’s parent(s) and/or other caregivers. The following intermediate care and outpatient services for children and adolescents will be covered effective 7/1/2019.
Intermediate Care Services for children and adolescents:
- Community-based acute treatment (CBAT) – intensive therapeutic services provided in a staff-secure setting on a 24-hour basis.
- Intensive community-based acute treatment (ICBAT) – provides the same services as CBAT for children and adolescents but at a higher intensity, roughly in between Residential and Inpatient levels of care.
- Mobile crisis intervention – short-term, mobile, on-site, face-to-face therapeutic response service that is available 24/7 to a child experiencing a behavioral health crisis to identify, assess, treat and stabilize a situation.
Outpatient services for children and adolescents:
- Intensive care coordination (ICC) – targeted case management to children and adolescents with a serious emotional disturbance.
- In-home behavioral services (IHBS) – a combination of behavior management therapy and behavior management monitoring provided where the child resides.
- In-home therapy (IHT) – therapeutic clinical intervention or ongoing therapeutic training and support provided where the child resides.
In addition, the following outpatient services for children and adolescents will be covered in the future - effective 7/1/2020:
- Family support and training (FS&T) – a service provided to a parent or other caregiver of a child to improve the capacity of the parent or caregiver to ameliorate or resolve the child’s emotional or behavioral needs and to parent.
- Therapeutic mentoring (TM) services – services provided to a child designed to support age-appropriate social functioning or to ameliorate deficits in the child’s age-appropriate social functioning.
Please see your benefit handbook for more benefit details.
If you need assistance locating a provider, please contact us at (888) 777-4742.
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
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
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.
Award-winning care management programs
Whatever your health concerns, Harvard Pilgrim’s nurse care managers can support you in reaching your wellness goals through our population health programs and offerings.
For example, our specialized nurses offer personal support. For example, they help members expecting a baby to have the healthiest possible pregnancy. They support members living with multiple or complex conditions—such as chronic kidney disease. They can also help you manage and learn more about specific conditions such as diabetes, asthma, cancer and heart health, 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, log in to your account to send us a confidential email. Or you can call us at (866) 750-2068.