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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyHarvard Pilgrim COB Claims Policy Update | OpenPay…
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    Currentharvard pilgrim health carePolicy N/A

    Coordination of Benefits (COB) Claims

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    Governs how Harvard Pilgrim processes coordination of benefits claims (including rules for primary/secondary payer determination, filing deadlines, special state rules, and submission addresses) for members except those in Choice or Choice Plus via Passport Connect. Affects providers and members when multiple coverages exist.

    Policy Summary
    Payerharvard pilgrim health care
    PolicyCoordination of Benefits (COB) Claims
    Policy CodePolicy N/A
    Change TypeNon‑material removal
    Effective DateN/A
    Last ReviewJan 1, 2024
    Next Review DateN/A
    Key ActionFollow Harvard Pilgrim procedures for referral, notification, and prior authorization when Harvard Pilgrim is secondary.
    SourceLink
    POLICY UPDATE CHANGES

    Removed Connecticut Retroactive Denial section.

    90 daysStandard filing limit for COB claims (secondary carrier)

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    120 days
    Maine filing limit when Harvard Pilgrim is secondary
    180 daysNew Hampshire filing limit for retroactive primary denials
    Birthday RuleDependent primary payer determination
    COB P.O. BoxesClaims & correspondence addresses

    Coordination of Benefits Determination & Filing Rules

    COB determination and filing criteria

    Rules used to determine primary versus secondary payer and requirements for claim submission.

    Dependent primary payer - Birthday Rule: When both parents have family coverage under different plans, the primary carrier for dependents is the plan of the parent whose birthday falls nearest to January 1 in the calendar year.
    Custody/Court Order Exception: A divorce decree, child custody determination or court order may override the Birthday Rule; Harvard Pilgrim will process claims per the court order or decree.

    Standard Filing Limit (Harvard Pilgrim secondary)

    • Claims must be received by Harvard Pilgrim within 90 days of the date on the primary carrier's Explanation of Benefits (EOB).
    • Claims submitted beyond the 90-day filing limit or without a copy of the primary carrier's Explanation of Payment/Benefits (EOP/EOB) will be denied.
    Maine filing variation (Harvard Pilgrim secondary): In Maine, claims must be submitted within 120 days from the date the primary insurer processed the claim or retroactively denied a previously paid claim (date shown on the primary insurer's EOB).

    New Hampshire retroactive termination variation (Harvard Pilgrim secondary)

    • When the primary carrier has retroactively terminated a policy, claims must be submitted within 180 days from the date the primary insurer retroactively denied a previously paid claim (date shown on the primary insurer's EOB).
    • This 180‑day rule does not apply if the primary carrier terminated under normal (non‑retroactive) circumstances.

    Dental COB determination

    • Harvard Pilgrim uses a procedure‑based model for dental claims: covered oral surgery benefits — Harvard Pilgrim is primary.
    • Preventive and pediatric preventive dental benefits — dental carrier is primary.

    Medicare coordination rules

    • Primary/secondary status depends on member age, employment status, and employer size per CMS rules.
    • Employer size thresholds affect determination (notably 20 and 100 employee thresholds as specified in CMS guidance).
    • For members with Medicare due to end‑stage renal disease (ESRD), contact Harvard Pilgrim Insurance Liability and Recovery Specialist for determination (888‑888‑4742, ext. 38999).

    Payment and documentation requirements

    • When Harvard Pilgrim is secondary, the primary insurer's EOP/EOB must match the date of service, member name, and charged amount for the claim to be processed.
    • No balance billing to Harvard Pilgrim or members when Harvard Pilgrim is primary or secondary per policy; if other insurance is later identified, Insurance Liability Recovery (ILR) may recover or adjust payments.
    • Providers must follow Harvard Pilgrim policies and procedures related to referral, notification, prior authorization and prior approval when Harvard Pilgrim is secondary.

    Coding & Medicare Coordination Details

    Dental COB rulesmixed
    Procedure-based model for determining primary payer on dental claims (oral surgery = Harvard Pilgrim primary; preventive/pediatric preventive = dental carrier primary).
    Employer size thresholds for Medicare coordination
    Employer size thresholdsAge and employment status rules use employer-size thresholds of 20 and 100 employees to determine whether Medicare or Harvard Pilgrim is primary or secondary.
    20-employee threshold (Age 65+, actively working)If subscriber is age 65+ and actively working and employer has >= 20 employees, Harvard Pilgrim is primary (Medicare secondary). If employer has < 20 employees, Medicare is primary.
    100-employee threshold (Under age 65, actively working)If subscriber is under 65 and actively working and employer has >= 100 employees, Harvard Pilgrim is primary (Medicare secondary). If employer has < 100 employees, Medicare is primary.
    Not actively working (Under 65)If subscriber is under 65 and not actively working and employer has < 100 employees, Medicare is primary and Harvard Pilgrim is secondary.
    Retirement impact (Age 65+)If subscriber is age 65+ and retired, Medicare is primary from date of retirement and Harvard Pilgrim is secondary.

    Provider Requirements and Recovery Processes

    Prior Authorization

    Prior authorization and prior approvals required when Harvard Pilgrim is secondary

    Follow Harvard Pilgrim policies and procedures related to referral, notification, prior authorization and prior approval for reimbursement when Harvard Pilgrim is secondary. Claims are paid according to Harvard Pilgrim's payment policies and procedures, and no balance bill can be submitted to Harvard Pilgrim or its members. When Harvard Pilgrim is secondary, the primary insurer's EOP must have date of service, member name, and charged amount that match the claim or the claim will be denied for incorrect EOP.

    • Adhere to referral, notification, prior authorization and prior approval requirements before submitting secondary claims.
    • Ensure the primary insurer's EOP matches date of service, member name, and charged amount to avoid denial for incorrect EOP.
    • Do not balance bill Harvard Pilgrim or its members.
    Denial Risk

    Insurance Liability Recovery (ILR) will determine primary payer and adjust claims

    Terms & Filing Limits

    Birthday Rule
    Birthday Rule definitionWhen both parents have family coverage under two different health plans, the primary carrier for dependents is the insurance of the parent whose birthday falls nearest to January 1 in the calendar year.
    Example (mother Feb 23; father Nov 12)Mother's plan is primary because her birthday (Feb 23) is nearer to January 1 than the father's (Nov 12).
    Override conditionsA divorce decree, child custody order, or court order may override the Birthday Rule (see exceptions).
    Filing limits and state variations
    Standard filing limitClaims submitted when Harvard Pilgrim is secondary must be received within 90 days of the date on the primary carrier's Explanation of Benefits (EOB).
    Maine variationIn Maine, the filing limit is 120 days from the date the primary insurer processed the claim or retroactively denied a previously paid claim when Harvard Pilgrim is secondary.
    Policy Summary
    Payerharvard pilgrim health care
    PolicyCoordination of Benefits (COB) Claims
    Policy CodePolicy N/A
    Change TypeNon‑material removal
    Effective DateN/A
    Last ReviewJan 1, 2024
    Next Review DateN/A
    Key ActionFollow Harvard Pilgrim procedures for referral, notification, and prior authorization when Harvard Pilgrim is secondary.
    SourceLink
    On This Page
    Coordination of Benefits Determination & Filing RulesCoding & Medicare Coordination DetailsProvider Requirements and Recovery ProcessesTerms & Filing Limits

    If Harvard Pilgrim pays or denies a claim and is later informed that other insurance exists, an Insurance Liability Recovery (ILR) investigator will determine the primary payer and adjust the claim accordingly.

    • ILR may pursue recovery or adjust previously paid or denied claims based on newly discovered coverage.
    New Hampshire variationIn New Hampshire, for retroactive primary terminations, the filing limit is 180 days from the date the primary insurer retroactively denied a previously paid claim (does not apply if primary terminated under normal circumstances).