Back to Insights and Updates for ProvidersJanuary 2024

Important tips to minimize denials

Harvard Pilgrim Health Care Commercial

As we continue migrating Tufts Health Plan commercial members to Harvard Pilgrim Health Care commercial products, we want to offer the following tips to ensure a smooth process and accurate claims reimbursement.

General tips

Ask for the member’s ID card: Every member who has a medical plan change will receive a new member ID card, as part of our standard open enrollment and renewal processes. Members are always instructed to present any new member ID card that they receive to their providers to ensure accuracy in billing, claims, and payments. We also encourage your practice’s office staff to request an up-to-date copy of the member’s ID card at the time of service. The Member Identification Cards policy in our Harvard Pilgrim commercial Provider Manual offers details on member ID cards and a sample image.

Check eligibility: Verifying eligibility is essential to determine coverage, deductibles, and copayments. Harvard Pilgrim recommends that providers verify member eligibility, electronically or by telephone, at the point of service. You can check the eligibility of Harvard Pilgrim Health Care commercial members electronically via HPHConnect, our secure provider portal, or the EDI network NEHEN. Please refer to the Determining Eligibility policy in the Harvard Pilgrim commercial Provider Manual for more details.

Requesting PA for services at facilities

When submitting an authorization request to Harvard Pilgrim via HPHConnect, please keep in mind that if the service is being performed at a facility (such as a surgical day center, ambulatory surgicenter, outpatient hospital, etc.) it’s important to list the facility NPI in the servicing/billing provider field. If a physician is listed in this field, rather than the facility, your claim will deny.

Please only include the provider in this field if the service is being performed in the medical provider’s office.

Audrey Kleinberg,
Director, Provider Relations & Communications

Annmarie Dadoly,
Senior Manager, Provider Communications

Joseph O’Riordan, Susan Panos, Ryan Francis, Stephen Wong,

Kristin Edmonston,
Production Coordinator

Kristina Cicelova,
Graphic Designer