Currentharvard pilgrim health carePolicy N/A

Referral Policy and Procedures

Governs when referrals are required for specialty care and the roles/responsibilities of referring and servicing providers for Harvard Pilgrim Health Care members; affects PCPs, specialists, and provider billing/authorization staff for applicable HMO, POS, PPO, Medicare Enhance and state-specific products.

Policy Summary

Payerharvard pilgrim health care

PolicyReferral Policy and Procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPCPs must submit referral requests prior to services for HMO/POS members in MA and RI using HPHConnect or NEHEN (or fax) so an approved referral transaction is available for reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

364 daysvalidity of standing referrals

90 daysretroactive referral deadline

800-708-4414Provider Service Center

617-509-4297fax for referrals

Box 17/17bCMS-1500 fields

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When Referrals Are Required and Operational Rules

inv-01: Coverage criteria and operational rules

Which members require referrals and notable exceptions

Referrals for most specialty care are required for members enrolled in Harvard Pilgrim's HMO and POS plans.

Exceptions

POS plan members may receive specialty care without a referral (members may self-refer to in-network providers for routine eye exams and routine OB/GYN services).
Referrals are not required for members enrolled in PPO or Medicare Enhance plans.
For Open Access HMO and POS products, no referral is required to see a contracted specialist.
Harvard Pilgrim does not require referrals for behavioral health services; members should contact Member Services using the phone number on their ID card for assistance accessing mental health and substance use services.

A claim for services rendered by a covering PCP who does not participate in the member's care unit requires evidence of a referral.

If a PCP initiates an in‑network retroactive referral, it must be received no later than 90 days from the date of service.90 days

Standing referrals are valid for 364 days and require the specialist's agreement to the treatment plan and regular information flow to the PCP.

inv-02: Referral evidence and timing criteria

Documentation requirements for coverage of referred services

Evidence of referral must be included on the claim; for specialists, include the referring PCP's name (CMS‑1500 Box 17) and the referring PCP's NPI (CMS‑1500 Box 17b).

Failure to provide complete referral information, including accurate referring provider name and Harvard Pilgrim provider identification number or NPI on the claim, will result in an administrative denial.

PCP‑initiated in‑network retroactive referrals must be received within 90 days of the date of service; for claims resubmission or appeals, follow the Provider Manual processes.90 days

Maine direct health care providers may make referrals and should submit evidence of a referral by contacting the Provider Service Center at 800‑708‑4414 rather than using the CMS‑1500 fields process.

Claim-level Evidence and Coding Fields

claim form fieldsmixed

Box 17	Referring PCP's name
Box 17b	Referring PCP's National Provider Identifier (NPI)

consequencesmixed

administrative denial

Failure to provide complete referral information, including accurate referring provider name and Harvard Pilgrim provider identification number or National Provider Identifier (NPI) on the claim, will result in an administrative denial.

special submission instructionsmixed

Maine direct health care providers

Maine direct health care providers should contact the Provider Service Center at 800-708-4414 to submit evidence of a referral.

Retroactive referral timeframe

Retroactive referral timeframePCP-initiated in-network retroactive referrals must be received no later than 90 days from the date of service.

Applies toIn-network PCP-initiated retroactive referrals

Consequence of late submissionClaims may be administratively denied if referral not received within 90 days.

Referral Submission, Authorizations, and Claim Evidence

Prior Authorization

Authorization required for non‑participating / covering providers

Referral to a non‑participating provider (outside the Harvard Pilgrim network) requires prior authorization from Harvard Pilgrim. This authorization requirement does not apply to POS, PPO, or Medicare Enhance members. When a covering PCP who is not part of the member's care unit provides services, claims also require evidence of a referral or Harvard Pilgrim authorization.

Applies when referring or using non‑participating/covering providers
Not applicable to POS, PPO, or Medicare Enhance members

Documentation Required

State-specific authorization / referral evidence (ME & NH)

In Maine and New Hampshire, specialist claims for most services require evidence that the specialist provided care at the request of the member’s PCP; this is satisfied by filing referral information on the claim (see 'Specialists: Filing Evidence of Referral' below). In Maine, direct health care providers (recent terminology updates may rename this role) may also make referrals; special submission instructions apply (contact Provider Service Center).

Maine: direct health care providers may make referrals — contact Provider Service Center at 800‑708‑4414 for instructions
NH/ME: specialist claims generally require evidence of a referral

Documentation Required

Claim evidence requirements for referrals

To file evidence of a referral on the CMS‑1500 claim form, include the referring PCP’s name in Box 17 and the referring PCP’s NPI in Box 17b. Failure to provide complete and accurate referral information (referring provider name and Harvard Pilgrim provider ID or NPI) will result in an administrative denial. For Maine direct health care provider referrals, follow the Provider Service Center instructions rather than the standard CMS‑1500 process.

CMS‑1500 Box 17: Referring PCP's name
CMS‑1500 Box 17b: Referring PCP's NPI
Incomplete/incorrect referral info may cause administrative denial

Key Terms and Evidence of Referral

When referrals are required

General ruleReferrals for most specialty care are required for members enrolled in Harvard Pilgrim's HMO and POS plans.

Open Access exceptionNo referral required for Open Access HMO and POS products to see a contracted specialist.

PPO/Medicare EnhanceReferrals are not required for members enrolled in PPO or Medicare Enhance plans.

Standing Referral

DefinitionA standing referral may be made when the PCP determines it is appropriate for a participating specialist to routinely treat a patient for a chronic or continuing condition.

Specialist responsibilitiesSpecialist must agree to a treatment plan and provide the PCP with necessary clinical and administrative information on a regular basis.

Validity periodStanding referrals are valid for 364 days.

Member's PCP — verification methods

Primary verification methodsAccess electronic eligibility via HPHConnect or NEHEN to verify member eligibility and PCP of record.

PCP panel reportReview the most current PCP panel report via HPHConnect to confirm PCP of record.

Provider Service CenterCall the Provider Service Center at 800-708-4414 to verify PCP of record.

Member Services for on-the-spot changesMembers can change PCP at time of service by calling Member Services at 888-333-4742; note a PCP cannot be retroactively assigned.

Evidence of referral

Required claim evidenceInclude referring PCP's name and NPI on the CMS-1500 claim form (Box 17 and Box 17b) to indicate evidence of a referral.

Covering PCP claimsA claim for services rendered by a covering PCP who does not participate in the member's care unit also requires evidence of a referral.

Failure to provide complete infoFailure to provide complete referral information, including accurate referring provider name and Harvard Pilgrim provider ID or NPI, will result in an administrative denial.

Maine direct health care providersMaine direct health care providers should contact the Provider Service Center at 800-708-4414 to submit evidence of a referral instead of the CMS-1500 process.