Currentharvard pilgrim health carePolicy N/A

Referral Denial Appeals

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Governance of provider appeals for claims denied due to missing or invalid primary care provider (PCP) referrals; applies to Harvard Pilgrim Health Care providers and claim submitters (excludes Choice/Choice Plus through Passport Connect).

Policy Summary

Payerharvard pilgrim health care

PolicyReferral Denial Appeals

Policy CodePolicy N/A

Change TypeAdministrative — no material changes

Effective DateN/A

Last ReviewJul 30, 2025

Next Review DateN/A

Key ActionSubmit a completed Request for Claim Review Form and a corrected CMS-1500 with the PCP name and NPI in box 17/17b; correctable claims within 90 days may be resubmitted as replacement claim with bill type 7.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

180 daysstandard appeal filing limit

30 daysdetermination timeframe

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Currentharvard pilgrim health carePolicy N/A

Referral Denial Appeals

Customize your policy alerts

Sign up for all harvard pilgrim health care policy alerts

Know when harvard pilgrim health care releases new policies or updates existing guidance.

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Policy Summary

Payerharvard pilgrim health care

PolicyReferral Denial Appeals

Policy CodePolicy N/A

Change TypeAdministrative — no material changes

Effective DateN/A

Last ReviewJul 30, 2025

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

180 daysstandard appeal filing limit

30 daysdetermination timeframe

Appeal Consideration Criteria

Appeal consideration criteria

Requirements and timelines to have a referral denial appeal considered:

Appeal must be received no later than 180 days from the original Explanation of Payment (EOP) date; any appeal received after this filing limit will not be considered; members cannot be held liable for claims denied solely for exceeding the appeal filing limit.

All provider appeals must be submitted with a completed Request for Claim Review Form; claims submitted without this form will be treated as a first submission and may result in denial.

Referral appeals must include a corrected CMS-1500 claim form with the PCP's valid provider name and National Provider Identifier (NPI) in box 17/17b.

Provide supporting documentation that substantiates the reason for review, including evidence of referral when applicable.

If an appeal is complete and received within the 180-day filing limit, Harvard Pilgrim will issue a determination within 30 days of receipt.

Resubmission and correction pathways

Claims denied for missing/invalid PCP referral that are within 90 days from the date of service may be corrected and resubmitted as a replacement claim (bill type 7) via paper or EDI, or resent electronically if within the initial filing limit.
If the referral appeal request is within the initial filing limit from the date of service, resend the claim electronically after correcting the missing or incorrect information and include the completed/corrected information on the new transmission.
For appeals that are over the initial filing limit from the date of service, follow the paper appeal submission process; resending electronically when the date of service is over the initial filing limit will result in a filing limit denial.

Second-level appeal: A second-level appeal may be submitted when the original denial is upheld; second-level appeals must be submitted within 90 days from the date of the original denial and include additional substantiating information.

Claim Forms, Billing Instructions, and Deadlines

claim form and billing instructionsmixed

CMS-1500 box 17/17b	PCP provider name and NPI required
bill type 7	Use for replacement claim submissions when correcting referral within 90 days

appeal filing deadlines

Standard appeal filing limitAppeal must be received no later than 180 days from the original Explanation of Payment (EOP) date; appeals received after this limit will not be considered and members cannot be held liable for claims denied for exceeding the filing limit.

Second-level appeal deadlineSecond-level appeals must be received within 90 days from the date of the original denial.

Determination timeframeHarvard Pilgrim will make a determination within 30 days following receipt of a complete appeal.

Appeal Submission and Resubmission Actions

Prior Authorization

Submit Request for Claim Review + corrected CMS-1500; resubmission rules

Submit a completed Request for Claim Review Form and include a corrected CMS-1500 with the PCP's valid provider name and NPI in box 17/17b. For claims denied for a missing/invalid PCP referral that are within 90 days from the date of service, correct and resubmit as a replacement claim (paper or EDI) using bill type 7 or resend electronically if still within the initial filing limit; appeals over the initial filing limit must follow the paper appeal submission process.

Claims submitted without a Request for Claim Review Form will be treated as a first submission and may be denied.
Provide supporting documentation that substantiates the reason for review, including evidence of referral as applicable.
If within the initial filing limit, resend the claim electronically with corrected information; if over the initial filing limit, submit via paper per the appeal process.
Use bill type 7 for replacement claim submissions when correcting referral information within 90 days of service.

Key Definitions and Typical Scenarios

appeal request definition

DefinitionAn appeal request for a claim whose original reason for denial was due to an invalid or missing PCP referral.

Scope example — late but within filing limitA claim denied for a missing/invalid PCP referral that is greater than 90 days from the date of service and within 180 days from the original denial.

Scope example — POS member paymentA claim for a POS member paid at the out-of-network rate due to invalid/missing PCP referral information on the claim form.

typical scenarios

Claim timing scenarioClaims denied more than 90 days but within 180 days from date of service may be appealed or resubmitted per filing limits.

POS member out-of-network paymentClaims for POS members paid at out-of-network rate due to missing/invalid PCP referral information are examples of referral-denial scenarios.