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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyHarvard Pilgrim filing limit appeals policy update…
    Ask Trek AI about this page
    Currentharvard pilgrim health carePolicy N/A

    Filing Limit Appeals

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    Governs submission, documentation, and timelines for appeals of claims denied for untimely filing for Harvard Pilgrim members (excludes Choice/Choice Plus via Passport Connect). Affects providers submitting claim appeals.

    Policy Summary
    Payerharvard pilgrim health care
    PolicyFiling Limit Appeals
    Policy CodePolicy N/A
    Change TypeClarified (administrative links updated)
    Effective DateN/A
    Last ReviewJul 30, 2025
    Next Review DateJul 30, 2025
    Key ActionSubmit filing limit appeals within 90 days of the original EOP with the Request for Claim Review Form, claim form (CMS-1500/ADA/UB-04), and supporting documentation.
    SourceLink
    POLICY UPDATE CHANGES

    Updated links.

    90 daysstandard appeal filing limit from original EOP date

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    120 days
    Maine COB filing limit
    180 daysNew Hampshire COB filing limit
    365 daysMA behavioral health COB filing limit
    Providers not liableMember liability

    Filing Limit Appeal Criteria

    Filing Limit Appeal Criteria

    Appeals will be reviewed only if submitted within the applicable timeframes and accompanied by the required documentation. Documentation requirements vary by appeal type.

    All filing limit appeals must be received within the applicable filing limit timeframe and include required forms and supporting documentation.

    ALL of the following

    • Required forms (all appeals)

      • Completed Request for Claim Review Form (claims submitted without this form will be treated as a first submission and may be denied).
      • CMS-1500, ADA, or UB-04 claim form matching the charges being appealed.
    • Supporting documentation that validates and cross-references the claim (must include patient name, date(s) of service, charges being appealed, and date the first claim was submitted to Harvard Pilgrim or proof the claim was sent to another insurer).
    Standard time limit: Filing limit appeals must be received within 90 days of the original EOP date; any appeal received after the applicable filing limit will not be considered and cannot be re-appealed.>= 0

    Members cannot be held liable for claims denied solely for exceeding the appeal filing limit.

    Acceptable supporting documentation (general/EDI)

    • Copy of an EDI vendor report indicating the claim was accepted for processing by Harvard Pilgrim within the filing limit period.
    • Harvard Pilgrim Response Report or information from the 277 Acknowledgement (277 ACK).
    • Computerized patient account ledger printout with the submission date circled (acceptable only in specific circumstances per 'Misidentified Member' guidance).

    Coordination of Benefits (COB) supporting documentation and state-specific timeframes

    • Paper claim: Explanation of Benefits from the other insurer showing timely submission to Harvard Pilgrim within 90 days from the date the other insurer processed the claim; or EDI claim: prior payer claim adjudication information including date of remittance showing timely submission to Harvard Pilgrim.
    • Retraction letter or request to refund from the other insurer when applicable.
    • State-specific COB filing limits: Maine — 120 days from the date the primary insurer processed the claim or retroactively denied a previous claim; New Hampshire — 180 days from the date the primary insurer retroactively denied a previously paid claim; Massachusetts (behavioral health) — 365 days from the date of denial.

    Misidentified member appeals

    • Acceptable documentation includes proof that another insurer was billed or the member was billed (other insurer's denial EOP or plan correspondence plus copy of patient ledger showing patient billing and discovery of Harvard Pilgrim insurance).
    • If other plan correspondence does not specifically link to the claim, hand-write patient name, date(s) of service, charges being appealed, and the date the first claim was submitted to Harvard Pilgrim on the letter.
    • Claims more than one year old from the HPHC denial date will not be considered for filing limit appeal.

    Second-level appeals

    • Providers may submit additional supporting documentation for any filing limit appeal denied for insufficient documentation if received within 90 days from the original denial date.
    • If a denial is upheld on re-appeal, Harvard Pilgrim will not consider subsequent appeals.

    Claim Form and Timeframe Codes

    Required claim formsmixed
    CMS-1500CMS-1500 claim form
    ADAADA claim form
    UB-04UB-04 claim form
    Appeal filing timeframes — standard and state-specific COB exceptions
    Standard filing limit90 days from the original EOP date
    Maine COB exception120 days from the date the primary insurer processed the claim or retroactively denied a previous claim
    New Hampshire COB exception180 days from the date the primary insurer retroactively denied a previously paid claim
    Massachusetts behavioral health COB exception365 days from the date of the denial

    Filing and Submission Requirements

    Documentation Required

    File appeal within 90 days with required forms and documentation

    Submit filing limit appeals within 90 days of the original Explanation of Payment (EOP) date and include a completed Request for Claim Review Form, the original claim form (CMS-1500/ADA/UB-04), and supporting documentation. Mail provider claim appeals to Harvard Pilgrim Health Care P.O. Box 699183, Quincy, MA 02269-9183.

    • Completed Request for Claim Review Form (appeals submitted without this form will be treated as a first submission and may be denied).
    • CMS-1500, ADA, or UB-04 claim form.
    • Supporting documentation that includes patient name, date(s) of service, charges being appealed (must match claim form), and date the first claim was submitted to Harvard Pilgrim or proof it was sent to another insurer.
    Denial Risk

    Submit additional documentation within 90 days for second-level review

    Key Definitions

    Filing Limit Appeal — definition and scope
    DefinitionAn appeal request for a claim whose original reason for denial was untimely filing; includes first‑time claim submission denials, coordination of benefits (COB) filing limit appeals, misidentified member appeals, and second level appeals.
    Scope — first‑time submissionCovers claims that denied for untimely filing on first submission to Harvard Pilgrim.
    Scope — COB scenariosIncludes claims over the 90‑day initial filing limit but within applicable COB timeframes (see state exceptions).
    Scope — second levelIncludes second level appeals when additional documentation is submitted following an initial denial for insufficient documentation (subject to 90‑day re‑appeal window).
    Claims Not Filed within 90 Days — definition
    Definition
    Policy Summary
    Payerharvard pilgrim health care
    PolicyFiling Limit Appeals
    Policy CodePolicy N/A
    Change TypeClarified (administrative links updated)
    Effective DateN/A
    Last ReviewJul 30, 2025
    Next Review DateJul 30, 2025
    Key ActionSubmit filing limit appeals within 90 days of the original EOP with the Request for Claim Review Form, claim form (CMS-1500/ADA/UB-04), and supporting documentation.
    SourceLink
    On This Page
    Filing Limit Appeal CriteriaClaim Form and Timeframe CodesFiling and Submission RequirementsKey Definitions

    Providers may submit additional supporting documentation for a filing limit appeal that was denied for insufficient documentation if the documentation is received within 90 days from the original denial date; if the denial is upheld on re-appeal, no further appeals will be considered.

    • Submit supplementary documentation within 90 days of the original denial date.
    • If Harvard Pilgrim upholds the denial on re-appeal, subsequent appeals will not be considered.
    A claim not on file with Harvard Pilgrim within 90 days from the date of service.
    EffectClaims not filed within this 90‑day period are subject to denial for untimely filing and generally will not be eligible for appeal beyond the filing limit.
    Member liabilityMembers cannot be held liable for claims denied solely for exceeding the appeal filing limit.
    Coordination of Benefits (COB) — definition
    DefinitionA claim that is over the 90‑day initial filing limit but is within 90 days of the Explanation of Payment (EOP) or remittance from the other insurer, allowing coordination of benefits consideration.
    Acceptable documentationPaper claim: EOB from the other insurer showing timely submission to Harvard Pilgrim; EDI claim: prior payer adjudication information including remittance date; or retraction/refund request from the other insurer.
    State timeframe variationsCOB submission timeframes vary by state (see specific exceptions for Maine, New Hampshire, Massachusetts).
    Misidentified Member — definition
    DefinitionWhen the member did not identify him/herself as a Harvard Pilgrim member at the time of service.
    Appeal windowClaims where the member was misidentified are evaluated per filing limit rules; misidentified member claims more than one year old from the HPHC denial date will not be considered for filing limit appeal.
    Required proofAcceptable supporting documentation includes proof that another insurer was billed or that patient billing occurred (see supporting documentation list).