- Our Plan
Compliance with federal requirements, plan and member Identification (ID) card information.
- General Coverage Information
A summary of CMS requirements pertaining to the Harvard Pilgrim Medicare Advantage benefit plan.
- Provider Roles and Responsibilities
Provider agreement, provider anti-discrimination, non-acceptance and termination, termination of a provider contract with cause, medical records, network participation, provider participation and responsibilities.
- Medical Records Requests and Submission of Encounter Data
Information on confidentiality and general consent, encounter data submission and reporting, encounter data for risk adjustment purposes, and risk adjustment data validation (RADV) audits.
- Delegation Activities
Provider responsibilities related to delegation activities.
- Clinical Credentialing and Recredentialing
Provider credentialing prerequisites; credentialing and recredentialing information; notification of approval, denial/termination; changing provider enrollment information and ongoing monitoring.
- Facility Credentialing and Recredentialing
Facility credentialing and recredentialing information; facility site visit exceptions; and accreditation agencies.
- Directory Accuracy and Suppression of Unverified Provider Information
Information on requirements regarding notification of provider information changes, enrollment of practice locations, and suppression of locations from the directory.
- Provider Inactivity and Administrative Termination of Network Providers
Harvard Pilgrim systematically reviews our provider network information on an annual basis, and may administratively terminate providers who have not provided services to our members for the immediate prior two years.
- Cell and Gene Therapy (CGT) Monitoring
Provider responsibilities related to Cell and Gene Therapy (CGT) Monitoring.