Provider Resources

On April 17, 2023, Point32Health, the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan, identified a cybersecurity ransomware incident that impacted our Harvard Pilgrim Health Care systems. The system limitations affect our Harvard Pilgrim Health Care commercial and Medicare Advantage Stride℠ (HMO)/(HMO-POS) plans. (Tufts Health Plan, Tufts Medicare Preferred, Tufts Health Public Plans and CarePartners of Connecticut systems have not been affected.)

As of June 21, 2023, most systems are back online, including the member, employer and broker portals, enrollment, claims and billing. Additionally, our service centers and support teams are at full capacity, and the public website has been restored.

Data latency may impact users’ ability to view the most up-to-date enrollment, eligibility and claims data. We will be working to bring information up to date over the coming weeks.

We have restored capabilities for 270/271 eligibility transactions for Harvard Pilgrim Health Care commercial plans and are ready to accept your 270/271 eligibility transactions. We are confident that it is safe to resume conducting these transactions with Harvard Pilgrim Health Care systems.

You can now check eligibility for Harvard Pilgrim Health Care commercial members via HPHConnect, the Provider Call Center, batch 270/271 transactions, and via trading partners. For these members, you have access to the same information available in the past, including member’s plan participation, PCP and benefit information including copayment, coinsurance, and other cost-share details. While we are working on updating the enrollment data, the information may not yet be current.

For Medicare Advantage Stride℠ (HMO)/(HMO-POS) members, providers can continue to access eligibility information through the Stride provider portal or through the Medicare Advantage Stride℠ (HMO)/(HMO-POS) Provider Service Center at 888-609-0692.

We recognize that providers could not check eligibility for Harvard Pilgrim Health Care commercial members. Please continue to provide care. If it is determined, after having received care, that the member was not eligible on the date of service, Point32Health will nonetheless reimburse providers for the services.

For Medicare Advantage Stride℠ (HMO)/(HMO-POS) members, providers can continue to access eligibility information through the Stride provider portal.

We are accepting claims for Harvard Pilgrim Health Care commercial and Medicare Supplement members again, as of June 15, 2023  — via EDI and paper. We are working on restoring claims submission functionality in HPHConnect and expect to have that available shortly.

We will be processing large volumes of claims each week to reimburse providers as quickly as possible. We anticipate that it may take approximately 6-10 weeks to fully address the claims backlog. Providers can review claims status via EDI and via HPHConnect. Given the volume of claims to process, you may not see a claim status immediately.

In addition, you should continue to submit claims for:

• Harvard Pilgrim Medicare Advantage Stride℠ (HMO)/(HMO-POS) members
• all Tufts Health Plan members, including Tufts Health Commercial Plans, Tufts Health Plan Senior Products, and Tufts Health Public Plans
• CarePartners of Connecticut members

Yes, we are extending the timely filing limit for affected claims to adjust for calendar days lost as a result of the outage. This change is intended to provide for the provider’s full timely filing period.

For purposes of timely filing, we are considering the period between April 17 and June 21 as the outage period.

For dates of service prior to April 17 with an original timely filing limit date of April 17 or beyond: In addition to restoring any calendar days lost due to the outage, the provider will have an additional 10-day grace period. For example, if you have a 90-day filing limit and exhausted 60 days prior to the outage, you will have the remaining 30 days after the outage plus an additional 10 days for a total of 40 calendar days to file claims.

For dates of service between April 17 and June 21: The provider will have the full timely filing limit without the additional 10-day grace period.For example, if a service was provided on June 1, the provider was unable to file the claim for 20 calendar days during the outage; as a result rather than the original filing date of Aug. 30, the new timely filing date is Sept. 19 (June 1 + 90 days + 20 days).

For claims in which the original timely filing limit ended or was exhausted prior to April 17: The outage did not affect the timely filing limit and the claim remains subject to original timely filing limits.

We will apply interest to commercial claims that were not processed due to the systems outage. Commercial claims with dates of service prior to April 17 (the date that Point32Health identified the cybersecurity incident), will be treated as though they were received on April 17, and we will calculate interest in accordance with regulatory interest payment rules. For claims with dates of service ending between April 17–June 18, interest will be calculated as of the date of service. Claims affected by the outage that are submitted after July 31, 2023
may not be eligible for interest, or if interest is appropriate it will be calculated based on the date of
receipt. A limited number of claims have been processed and paid between April 17 and June 19 without
interest applied; this subset of claims will have the interest applied and paid at a later date.

We are resuming normal operations for utilization management — including prior authorization, notifications, and referrals — for Harvard Pilgrim Health Care commercial, Medicare Supplement, and Medicare Advantage Stride͈℠ (HMO)/(HMO-POS) members, effective for new services with dates of service beginning July 24, 2023.

Our utilization management programs with vendors will also resume utilization management for new services with dates of service beginning July 24, 2023. This includes Optum/UBH for behavioral health services, as well as programs managed by Carelon (formerly AIM), NIA, OncoHealth and Progeny Health.

As we noted in previous communications, in light of the system outage, Harvard Pilgrim Health Care will not deny coverage due to lack of prior authorization for services rendered from April 15, 2023 through July 23, 2023, nor will we retroactively review requests made for that time period.

You can submit prior authorization requests as you have in the past. For commercial members, you can submit electronically through HPHConnect, by fax or by calling the Provider Service Center at 800-708-4414. For Medicare Advantage Stride℠ (HMO/HMO-POS) members, you can request an authorization through the IKA portal, by fax or by calling the Medicare Advantage Provider Service Center at 888-609-0692.

For details, please refer to the referral and authorization policies in the Provider Manuals, as well as the Vendor Programs page on the Harvard Pilgrim Health Care provider website. Our public Harvard Pilgrim Health Care provider website was brought back online on June 21, 2023, and includes all policies and tools you previously had access to including prior authorization and referral policies, medical necessity guidelines, and forms.

For dates of service that span the waiver period and extend beyond July 23, it’s important to notify us so we are able to coordinate continuity of care.

Please continue to submit your behavioral health claims for our Harvard Pilgrim Health Care members. Until further notice, Optum/UBH is waiving referral, authorization, and notification requirements for behavioral health services for members of Harvard Pilgrim Health Care commercial and Medicare Advantage Stride^SM (HMO)/(HMO-POS) plans. Optum/UBH is processing behavioral health claims and reimbursing providers without interruption.

Due to the continuous work on restoration efforts, we have made the decision to push back insourcing our Behavioral Health program, which was scheduled to occur on July 1 for our Harvard Pilgrim Health Care commercial members. By delaying the implementation, we can ensure the continuity of care for our members, while our staff continues work on the current outage.

There is no impact to Tufts Health Plan, Harvard Pilgrim Health Care Medicare Advantage Stride^SM (HMO)/(HMO-POS), and CarePartners of Connecticut members.

Although our rollout is delayed, there will be no interruption to care or provider access for our Harvard Pilgrim Health Care members. All Harvard Pilgrim Health Care members in New England and nationwide will be able to continue to see their providers as they do today based on their current health plan designs.

We will continue to build our behavioral health network in anticipation of the insourcing. If you are a behavioral health provider and you received a contracting packet from us, we encourage you to complete any necessary steps as soon as possible. This will help us offer a robust behavioral health network for our members and uninterrupted care to Harvard Pilgrim commercial members when insourcing occurs.

Until that time, Optum/United Behavioral Health will continue to provide behavioral health services for Harvard Pilgrim Health Care members; Tufts Health Plan behavioral health services will continue to be managed inhouse, with members receiving services from the existing Tufts Health Plan network of providers.

Please refer to the Behavioral Health section of the Integration FAQ for further details.

We resumed accepting claims from providers for Harvard Pilgrim Health Care commercial members as of June 15, and are issuing provider reimbursements via weekly check runs. You should submit claims for all lines of business including Harvard Pilgrim Health Care Commercial, Harvard Pilgrim Health Care Medicare Advantage Stride℠ (HMO)/(HMO-POS), Tufts Health Plan products (including Tufts Health Plan, Tufts Medicare Preferred, and Tufts Health Public Plans), and CarePartners of Connecticut.

We have established a temporary process to enroll new commercial members. This applies to new groups as well as adding members to existing groups. As part of this process, we will be issuing temporary member ID cards for newly enrolled Harvard Pilgrim commercial members. The temporary ID cards look similar to current Harvard Pilgrim cards; however, the ID card number will start with P3 rather than our standard HP. Please use this card as you would a permanent ID card, and keep in mind that you can file claims using this temporary member ID number when we begin accepting claims for Harvard Pilgrim commercial members again. Permanent ID cards will be issued once the system outage is resolved. Please update your records when the permanent ID is presented. We will reconcile our records and map any transactions submitted using the temporary member ID number to the permanent member ID number.  In the event that a new member needs services prior to receiving their temporary member ID, we will issue an eligibility verification letter, as we have in the past.

HPI is accepting and processing claims. Please be aware however that due to the outage, HPI is experiencing a delay in our normal claims turnaround time. We anticipate returning to our normal claims processing turnaround times in the next several weeks. Meanwhile, please be aware that if you have submitted a claim to HPI you may experience a delay in receiving notification that your claim has been received and in the processing of the claim. If you have submitted a claim and can’t find its status, please check back in a few days.

Please do not resubmit claims that you have already submitted to HPI — either electronically (to payer ID 04271 or 44723) or via paper (directly to HPI at PO Box 5199, Westborouth, MA 01581). Doing so, will cause further delays.

HPI’s prior authorization requirements remain in place, and HPI is continuing to process prior authorization requests.

You can now check eligibility for HPI members but please be aware that we are bringing eligibility information up to date. HPI can also provide verification of eligibility by telephone to providers who call the 800 number on member ID cards.

UnitedHealthcare manages administrative services in all regions for Passport, including eligibility and claims processing. Please continue to access UnitedHealthcare’s provider portal for transactions and information for Passport members.

• Claims: UnitedHealthcare is accepting and can process in-area and out-of-area claims. Please continue to submit claims to UnitedHealthcare for Passport members.
• Eligibility: Current eligibility for Passport members is available and can be verified on UnitedHealthcare’s provider portal.
• Prior Authorization: UnitedHealthcare is accepting and can process prior authorizations. Please continue to submit prior authorization to UnitedHealthcare for Passport members.
• Customer Service: For questions and support, providers may contact UnitedHealthcare at 877-842-3210. Members may contact UnitedHealthcare’s member services at 866-801-4409 or access information on UnitedHealthcare’s member portal.

Our top priority is continuing to provide access to care for our members. Point32Health is committed to providing coverage for all members during this time.

Our email systems, including secure email, have not been affected by this incident.

Harvard Pilgrim’s Provider Service Center has limited capabilities as noted above but can be reached in the following ways:

• Commercial: by email at provider_callcenter@point32health.org or by phone at 800-708-4414
•  Medicare Advantage Stride℠ plans:  888-609-0692

Members who need urgent assistance can call the Member Services number listed on the back of their Harvard Pilgrim ID card, but should be aware that call volumes are higher than normal and have created longer wait times.

For questions about behavioral health services, Harvard Pilgrim members can call Optum/United Behavioral Health at 888-777-4742. For questions about Pharmacy services, members can call the following numbers:

• For specialty pharmacy help: 844-265-1705
• For OptumRx home delivery help: 855-258-1561
• For help with their OptumRx online account: 844-813-7271