Currentharvard pilgrim health carePolicy N/A

When a Referral is Not Required

Governs situations where primary care provider (PCP) referrals are not required for Harvard Pilgrim members and which services/providers are exempt; affects members and participating providers (applies except where Choice/Choice Plus via Passport Connect are specified).

Policy Summary

Payerharvard pilgrim health care

PolicyWhen a Referral is Not Required

Policy CodePolicy N/A

Change TypeAdministrative (contact info)

Effective DateN/A

Next Review DateN/A

Key ActionNo PCP referral is required for inpatient admissions, observation services and many ambulatory services when performed by participating providers; notify the plan for inpatient admissions.

SourceLink

POLICY UPDATE CHANGES

Updated web address for UnitedHealthcare and removed phone number.

7service categories

PPO/POS/Open Access/Medicareapplicable products

Requiredinpatient notification

Passport ConnectChoice exclusion

Services and Member Products That Do Not Require a PCP Referral

Policy Summary

Payerharvard pilgrim health care

PolicyWhen a Referral is Not Required

Policy CodePolicy N/A

Change TypeAdministrative (contact info)

Effective DateN/A

Next Review DateN/A

Key ActionNo PCP referral is required for inpatient admissions, observation services and many ambulatory services when performed by participating providers; notify the plan for inpatient admissions.

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.

ALL of the following

ANY of the following
- Open Access HMO
- POS
- PPO
- Medicare Enhance

ALL of the following

ANY of the following
- PCP covering physician services (if the covering physician participates in the member's care unit)
- Initial evaluation for outpatient physical therapy, occupational therapy, or speech/language therapy (physician prescription required)
- Acupuncture services
- Chiropractic services
- Routine eye examination
- Pediatric dental services
- Obstetric and gynecologic (OB/GYN) services (excluding Assisted Reproductive Technology services) provided by an obstetrician, gynecologist, certified nurse midwife or family practitioner, including routine annual exams, treatment of an acute or emergency OB/GYN condition, follow-up care for an acute or emergency OB/GYN condition, and maternity care

ALL of the following

No referral required when the limited service provider is contracted, meets Harvard Pilgrim's limited service provider requirements, and is recognized as a contracted participating limited service retail provider

ALL of the following

No referral required for treatment of an acute or chronic illness or injury that is immediate in nature and requires professional attention but is not life threatening when rendered by a Harvard Pilgrim contracted Free Standing Urgent Care Center

ALL of the following

ANY of the following
- Inpatient admissions: no PCP referral required (notification is required)
- Observation services: no PCP referral required
- Emergency room (ER) care: no PCP referral required; follow-up care must be approved by the PCP

Provider Notification and Urgent Care Rules

Documentation Required

Hospital admissions: notification required; ER follow-up needs PCP approval

Inpatient admissions do not require a PCP referral, but the provider must notify Harvard Pilgrim. Emergency room care does not require a PCP referral; however, any follow-up care after ER treatment must be approved by the member's PCP.

Inpatient admissions: notification required.
ER care: follow-up care must be approved by the PCP.

Prior Authorization

Urgent care at contracted free‑standing centers: no referral required

No PCP referral is required for treatment of acute or chronic non–life-threatening illnesses or injuries when care is rendered at a Harvard Pilgrim contracted Free Standing Urgent Care Center.

Applies to acute or chronic conditions that are immediate in nature but not life threatening.
Must be rendered by a Harvard Pilgrim contracted Free Standing Urgent Care Center.

Terminology

Out-of-network services

DefinitionServices performed by a non-participating provider.

Network implicationCare delivered by out-of-network providers is not considered performed by a participating/contracted provider for purposes of this policy.

Referral requirement impactOut-of-network status does not satisfy the policy’s condition of ‘performed by a participating provider’ for referral exemptions.

Limited service provider (retail medicine)

DefinitionMedical evaluation and treatment of minor health care issues in a retail setting by Harvard Pilgrim contracted limited service providers.

Participation requirementReferral is not required only when the limited service provider meets Harvard Pilgrim Health Care's limited service provider requirements and is recognized as a contracted participating limited service retail provider.

ScopeApplies to minor health care issues evaluated and treated in a retail (limited service) setting.

Referral conditionNo PCP referral required only if the provider is contracted and recognized as participating under this policy.

OpenPayer

When a Referral is Not Required

Services and Member Products That Do Not Require a PCP Referral

Network Status / Code References

Provider Notification and Urgent Care Rules

Terminology