For members enrolled in HMO plans, 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. If covered benefits are received from an out-of-network provider (non-plan provider) and the service is required due to one of the following reasons:
Under the circumstances previously listed, 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 responsible for any balance billing.
If covered benefits are received from a non-plan provider by a 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 responsible 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 previously listed, the member will be responsible for the full cost of the services.
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. Please contact Member Services at (888) 333-4742 if you have questions.
Prescription Drug Reimbursement Claim Form: PDF
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. While the Centers for Medicare and Medicaid Services (CMS) permits issuers to pend claims for services provided during the second and third months of the grace period, Harvard Pilgrim does not pend claims during this period.1
It is Harvard Pilgrim’s policy to pay all provider claims for dates of service during the second and third months of the grace period. Harvard Pilgrim does not pend claims during this period. Any provider payments made for services during the second and/or the third months of the grace period are subject to retraction by Harvard Pilgrim if the enrollee fails to pay the premium for those months.
The enrollee will be responsible for claims for covered services received during the second and/or third months 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.
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.
What requires prior authorization and who is responsible
Prior authorization must be obtained before receiving certain medical services, such as any kind of inpatient hospital care (aside from maternity care) by a Non-Plan Provider or Plan Provider outside the Service Area. If you use a Plan Provider located within the Service Area, he/she will seek prior authorization for you. To obtain prior authorization for medical services you should call 1-800-708-4414. To obtain prior authorization for Medical Drugs, you should call 1–844–387–1435.
If you obtain prior authorization when required, the Plan will pay up to the full benefit limit stated in this Benefit Handbook and your Schedule of Benefits. If you do not obtain prior authorization when required, you will receive coverage only for services later determined to be medically necessary and will be responsible for any applicable member cost sharing. For service received from a Non-Plan Provider, you will also be responsible for paying the Penalty amount stated in the Schedule of Benefits. Urgent pre-service prior authorization turnaround time is 1 business day of receipt. Non-urgent pre-service prior authorization turnaround is 2 business days of receipt.
If you need a medication that Harvard Pilgrim either doesn’t cover or limits, you or your provider can ask for an exception. Drugs are excluded from coverage if they are not listed on your plan’s formulary (prescription drug list). We will grant exceptions only for clinical reasons. If the drug is denied, you have the right to an external review.
Members can start the exception process by logging into our Old Member Dashboard and completing the online exception request process.
Providers can start the exception process by completing one of the formulary exception/prior authorization forms below and faxing it to our pharmacy benefits manager, OptumRx, at (844) 403-1029. They can also call OptumRx customer service at (855) 258-1561. OptumRx will need a statement from your provider explaining why an exception is medically necessary, including why a covered drug is not as effective as the requested drug. In Connecticut, Massachusetts and New Hampshire decisions will be made within two days of receiving your provider’s statement, in ME, a decision will be made within 72 hours or two business days (whichever is less) of receipt. For a faster decision, your provider must provide the necessary medical information with the initial request for an exception.
Your provider may request an expedited exception when you could seriously jeopardize your life, health or ability to regain maximum function if there is a delay in treatment, or if you are undergoing a current course of treatment using a non-covered drug. We will notify you of a decision no later than 24 hours after receiving your expedited request.
Your exception request will be considered by pharmacists and other clinicians as appropriate.
View or download forms:
If we deny your request, you may request an external review by an Independent Review Organization (IRO). An IRO review may be requested by a member, member's representative or prescribing provider by mailing, calling, or faxing the request to the following:
New Hampshire Insurance Department
Attn: External Review Unit
21 South Fruit Street, Suite 14
Concord, NH 03301
Phone: (800) 852-3416
External Review Applications may be faxed to (603) 271–1406, or sent by overnight carrier to the Department’s mailing address.
Harvard Pilgrim’s EOB is also known as an Activity Summary. You may find more information about Harvard Pilgrim’s activity summaries here.
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 to provide information for all other health benefits coverage you or your dependents may have.
Harvard Pilgrim’s Maine and New Hampshire Public Marketplace plan, provider and formulary data is publicly available in a machine-readable JSON format for use by the Centers for Medicare & Medicaid (CMS), software developers or other interested entities. View the URLs to the data.
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