Harvard Pilgrim Health Care Commercial Provider Manual

This online Provider Manual represents the most up-to-date information on Harvard Pilgrim Health Care’s Commercial products, programs, policies, and procedures. It has been developed as a reference tool for the providers and office staff who serve Harvard Pilgrim Health Care and Harvard Pilgrim Health Care of New England members, and contains information intended for all Harvard Pilgrim Health Care providers, including Medicare supplement providers. This Manual sets forth the policies and procedures that providers participating in the Harvard Pilgrim Health Plan Commercial network are required to follow.

Network Ops & Care Delivery Mgmt.

Local Care Unit (LCU) and Primary Care Provider (PCP) roles, credentialing, and care management.

Member Care

Information on member rights and responsibilities, determining eligibility, and collecting member payment.

eServices & Online Solutions

Policies and procedures for Harvard Pilgrim’s Web-based transaction service, HPHConnect.

Referral, Notification and Authorization

Policies and procedures related to referral, notification and authorization.

Billing & Reimbursement

Electronic and paper submissions, account reconciliation, and claim submission guidelines.

Payment Policies

Payment methodologies that apply to claims in general.

Appeals

Administrative and clinical appeals, filing limit appeals, and second level appeals.

Please note: References to Harvard Pilgrim Health Care, Harvard Pilgrim or HPHC in this manual also apply to its affiliate, Harvard Pilgrim Health Care of New England. To the extent that any provision of this Harvard Pilgrim Health Care manual is inconsistent with any provision of your contract with Harvard Pilgrim Health Care, the terms of the contract shall control. To the extent that any provision of this Harvard Pilgrim Health Care manual is inconsistent with any provision of our Harvard Pilgrim Health Care Member Agreement, the terms of the member agreement shall control.