Back to Insights and Updates for ProvidersAugust 2023

Billing Medicare members for non-covered services 

Harvard Pilgrim Stride (HMO) Medicare Advantage  |  Tufts Health Plan Senior Products

We would like to provide some reminders regarding the steps a contracted provider must take prior to billing members of our Harvard Pilgrim Health Care and Tufts Health Plan Medicare Advantage plans/Senior Products for non-covered services.

Members may come to their provider seeking a non-covered service, or you as a provider may determine that it is appropriate to provide a service or treatment that isn’t normally covered by the member’s Medicare Advantage/Senior Products plan. Please note that you cannot directly bill the member for that service unless the member has been formally advised by the plan that the service will not be covered. In order to bill the member, you must first request a plan review by submitting an organization determination request to the plan. If the plan makes a non-coverage determination and the member wants to proceed with treatment, you must obtain the member’s informed written consent, which must include the specified non-covered service as well as the specific charge to the member.

Submitting an organization determination  

Providers sometimes inform their patients that a service is non-covered and offer to provide the service in exchange for a cash payment without seeking an organization determination in advance from Harvard Pilgrim or Tufts Health Plan. This is an inappropriate billing practice and is not allowed by Point32Health or Medicare.

Before providing a non-covered service for a Medicare Advantage/Senior Products member and accepting payment for the service, providers are required to request an organization determination on the member’s behalf or advise the member to request such a determination. After an organization determination is requested, the provider and member will be notified of the decision. Both a denial notice from the plan, as well as valid informed consent from the member, must be received before the provider can bill the member.

You can submit an organization determination request for medical services in the following ways:

  • Harvard Pilgrim:
    • Phone: 1‐888‐609‐0692 (TTY: 711)
    • Fax: 1‐866‐874‐0857
    • Mail:     Harvard Pilgrim Health Care
      Attn: Stride Utilization Management
      1 Wellness Way Canton, MA 02021
  • Tufts Health Plan:
    • By fax to Precertification Operations: 617-972-9409

The appropriate course of action before prescribing a non-covered prescription drug is to submit a coverage determination request to the plan, which can be done via the following methods:

Tufts Health Plan Medicare Preferred
Attn: Pharmacy Utilization Management Department
1 Wellness Way Canton, MA 02021-1166

If the plan denies coverage, the provider must obtain the member’s informed consent before prescribing the drug.

Reminder: ABNs not valid for Medicare Advantage members   

As a reminder, the process of submitting an Advance Beneficiary Notice of Non-coverage (ABN) is applicable for Original Medicare only, and is not considered a valid form of denial notice for a Harvard Pilgrim or Tufts Health Plan Medicare Advantage/Senior Products member.   

More information  

For further details and instructions related to the correct process for billing members for non-covered services, please refer to Tufts Health Plan’s Senior Products Provider Manual and the Billing Members and Provider Roles and Responsibilities policies in the Harvard Pilgrim StrideSM (HMO)(HMO-POS) Medicare Advantage Provider Manual. 

Audrey Kleinberg,
Director, Provider Relations & Communications

Annmarie Dadoly,
Senior Manager, Provider Communications

Joseph O’Riordan, Susan Panos, Stephen Wong,

Kristin Edmonston,
Production Coordinator

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Graphic Designer