Currentharvard pilgrim health carePolicy N/A

Motor Vehicle Accident (MVA) Claims

Governs coordination of benefits, filing requirements, and documentation for claims related to motor vehicle accidents for Harvard Pilgrim members (excludes Choice/Choice Plus through Passport Connect). Affects providers submitting MVA-related claims and Harvard Pilgrim as secondary payer.

Policy Summary

Payerharvard pilgrim health care

PolicyMotor Vehicle Accident (MVA) Claims

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionBill the auto carrier first and include the auto insurer's exhaustion notice and primary EOB/EOP when submitting MVA-related claims to Harvard Pilgrim.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysstandard filing limit (after exhaustion notice)

120 daysMaine filing limit

180 daysNew Hampshire filing limit

$2,000Massachusetts PIP threshold

No pre-service billingMember billing protection

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MVA Claim Submission & Coordination Rules

MVA claim submission and coordination criteria

Claims related to motor vehicle accidents (MVAs) must meet the coordination, documentation, and timing requirements below when Harvard Pilgrim is the secondary payer.

ALL of the following

ALL of the following
- Bill the auto carrier first, if known, to expedite payment.
- Do not bill or require payment from members before MVA-related services are rendered; members must be protected from balance billing related to MVA claims.
ALL of the following
- Include the accident claim number and date of accident on the claim, when available.
- Provide the name and address of the PIP/MedPay insurance carrier.
- Attach the PIP/MedPay exhaust notice/letter from the auto carrier when applicable.
- If Harvard Pilgrim is secondary, submit a copy of the primary carrier's Explanation of Payment/Benefits (EOP/EOB) with the claim and exhaust letters.
ALL of the following
- Standard rule: Claim must be received within 90 days of the date posted on the MVA insurer's notification that benefits have been exhausted.
- Claims received beyond 90 days from the insurer's exhaustion date, or with an exhaustion notice that has no date, will be denied.
State-specific timing exceptions
- Maine: When coordinating with a primary insurer, the filing limit is 120 days from the date the primary insurer processed the claim or retroactively denied a previously paid claim (date on EOB).
- New Hampshire: For retroactive termination by the primary carrier, the filing limit is 180 days from the date the primary insurer retroactively denied a previously paid claim (date on EOB). This applies only when Harvard Pilgrim is secondary and the primary carrier has retroactively terminated the policy; it does not apply to normal terminations.
ALL of the following
- In Massachusetts, automobile insurance is primary until all benefits are exhausted up to $2,000 under Personal Injury Protection (PIP). MedPay is secondary to health benefits and PIP; certain members (Medicaid, Medicare, ERISA plans) must exhaust full $8,000 PIP benefits where applicable.
ALL of the following
- If Harvard Pilgrim paid or denied a claim and later determines the claim is MVA-related, an Insurance Liability Recovery investigator will determine the primary payer and adjust the claim accordingly.

Provider Requirements — Authorization, Referrals, and Documentation

Prior Authorization

Follow Harvard Pilgrim referral/prior authorization rules when secondary

Harvard Pilgrim's referral, prior authorization, and prior approval policies and procedures must be followed for Harvard Pilgrim to reimburse services when Harvard Pilgrim is the secondary payer. Claims are paid according to Harvard Pilgrim's payment policies and procedures; non‑covered benefits do not become covered because of an accident; and no balance bill may be submitted to Harvard Pilgrim or its members.

Follow Harvard Pilgrim referral, prior authorization and prior approval requirements before submitting claims for services when Harvard Pilgrim is secondary.
Do not submit balance bills to Harvard Pilgrim or members for MVA-related services.

Key Terms

PIP/MedPay definitions

Personal Injury Protection (PIP)Auto insurance coverage that is primary in Massachusetts until benefits are exhausted (up to $2,000); coordinated with health benefits for MVA-related claims

Medical Payments (MedPay)Auto insurance coverage that is secondary and in excess of any health benefit or PIP plan; coordinated with health benefits for MVA-related claims

Coordination practiceWhen MVA-related, auto coverages (PIP/MedPay) are coordinated with Harvard Pilgrim benefits; providers should bill the auto carrier first and include required MVA documentation when submitting to Harvard Pilgrim

Insurance Liability Recovery investigator

Insurance Liability Recovery investigator roleHarvard Pilgrim investigator who determines the primary payer and adjusts claims when a paid or denied claim is later identified as MVA-related

Adjustment authorityMay recover payments or reprocess claims based on determination of primary auto coverage

Member billing protectionNo balance billing to Harvard Pilgrim or members; investigator actions support enforcement of this protection

OpenPayer

Motor Vehicle Accident (MVA) Claims

MVA Claim Submission & Coordination Rules

State-specific PIP Limits & Coding Notes

Provider Requirements — Authorization, Referrals, and Documentation

Key Terms