Currentharvard pilgrim health carePolicy N/A

Member Appeals process

Describes Harvard Pilgrim Health Care's process for members, authorized representatives, and treating providers to request reviews (appeals) of coverage and benefit decisions for HMO, POS, and PPO members; excludes Choice/Choice Plus through Passport Connect SM and references UnitedHealthcare materials separately.

Policy Summary

Payerharvard pilgrim health care

PolicyMember Appeals process

Policy CodePolicy N/A

Change TypeAdministrative edits (non-material)

Effective DateN/A

Next Review DateN/A

Key ActionMembers, authorized representatives, or providers may request an appeal verbally or in writing; providers may file an appeal on behalf of a member (requires member authorization if an authorized representative acts).

SourceLink

POLICY UPDATE CHANGES

updated web address for United Healthcare and removed phone number

reviewed; administrative edits on 01/01/23

HMO/POS/PPOmember types covered

Choice/Choice Plusproducts excluded

1-5 daysresponse timeframe

availableexternal review option

Member Appeals and Coverage Criteria

Member appeals procedure

Appeal submission and follow-up process for HMO, POS, and PPO members:

Harvard Pilgrim provides a process for members, authorized representatives, and treating providers to request a review of decisions concerning benefits and coverage.

How to file an appeal

ONE of: Member submits appeal verbally or in writing to Member Services or directly to Appeals and Grievances.
ONE of: Provider submits an appeal on behalf of a member (verbally or in writing).
ONE of:

Policy Summary

Payerharvard pilgrim health care

PolicyMember Appeals process

Policy CodePolicy N/A

Change TypeAdministrative edits (non-material)

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Follow-up and external review options

Respond to requests for additional information within the timeframe requested (which may be from one to five business days, depending on the urgency of the appeal).1-5 business days depending on urgency
IF dissatisfied (fully-insured members): Case could be eligible for external review by an external review agency contracted with the state; review agency information is included in the determination letter.
IF dissatisfied (certain self-insured groups): Case could be eligible for review by an Independent Review Organization through a process coordinated by Harvard Pilgrim.

How to File an Appeal & Processing Steps

Prior Authorization

How to file an appeal

Members, a member's authorized representative, or providers may request an appeal verbally or in writing; providers may file an appeal on behalf of a member. Member Services Representatives forward verbal appeals to Appeals and Grievances. If an authorized representative is acting for the member, Harvard Pilgrim must receive written or verbal authorization from the member prior to initiation.

Documentation Required

Appeals processing steps

An Appeals and Grievances Analyst acknowledges receipt, may request necessary medical documentation, coordinates the investigation, provides the determination in writing to the member and requesting provider, and provides the requester with copies of any new or additional information received before a decision is rendered.

Analyst sends an acknowledgment letter to the member.
Analyst may request additional medical documentation (response required within 1–5 business days depending on urgency).
Analyst notifies member and requesting provider in writing of the determination.
Analyst provides requester copies of any new information prior to decision.

Key Definitions

Authorized representative

DefinitionAn individual acting on behalf of the member

Authorization requirementHarvard Pilgrim must receive written or verbal authorization from the member prior to initiation of the grievance

Who can actAuthorized representatives may file appeals or act for the member in the appeals process once authorized

Submission methodsAppeals may be requested verbally or in writing by an authorized representative on behalf of a member

Appeals and Grievances Analyst

RoleHarvard Pilgrim staff who manages appeal intake and processing

AcknowledgmentSends a letter acknowledging receipt of the appeal to the member

Documentation requestsRequests any necessary medical documentation to ensure a thorough review

Investigation coordinationCoordinates the investigation of the appeal

Determination and disclosureNotifies the member and requesting provider in writing of the determination and provides the requester copies of any new information prior to decision

OpenPayer

Member Appeals process

Member Appeals and Coverage Criteria

Coding and Response Time

How to File an Appeal & Processing Steps

Key Definitions