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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyHarvard Pilgrim appeals filing limits & docs | Ope…
    Ask Trek AI about this page
    Currentharvard pilgrim health carePolicy N/A

    Request for Additional Information Appeals

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    Governs provider appeal submissions for claims denied due to insufficient or missing information and outlines timelines, required documentation, and response processes; does not apply to Choice or Choice Plus products through Passport Connect.

    Policy Summary
    Payerharvard pilgrim health care
    PolicyRequest for Additional Information Appeals
    Policy CodePolicy N/A
    Change TypeAdministrative updates
    Effective DateN/A
    Last ReviewJan 1, 2023
    Next Review DateN/A
    Key ActionSubmit a completed Request for Claim Review Form with the original EOP, an HPHConnect or NEHEN claim detail screen, and supporting documentation.
    SourceLink
    POLICY UPDATE CHANGES

    Updated hyperlinks.

    Second level appeals filing limit submission time updated to 90 days.

    180 daysstandard appeal filing limit

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    90 dayssecond level appeal filing limit
    30 daysdecision timeframe
    P.O. Box 699183mailing address
    Choice/Choice Plusexcluded products

    Appeal Review Criteria

    Appeal review criteria

    Timelines and review outcomes for provider appeals.

    ALL of the following

    • Request for Additional Information appeals must be received no later than 180 days from the original Explanation of Payment (EOP) date.
    • Any appeal received after the applicable appeal filing limit will not be considered and cannot be appealed.
    • Members cannot be held liable for claims denied for exceeding the appeal filing limit.

    ALL of the following

    • If the appeal is received within the 180-day filing limit, Harvard Pilgrim will review the appeal.
    • A determination is made within 30 days following receipt of an appeal that is accompanied by the appropriate documentation.

    • Outcome

      • If the decision is upheld, the resolution letter outlines the reason(s) for upholding the original decision.
      • If the denial is reversed, the resolution letter explains that the claim will be adjusted in accordance with payment policy, member agreement, and hospital contract.

    ALL of the following

    • Second level appeals must be received within 90 days from the date of Harvard Pilgrim's appeal decision; requests beyond this 90-day filing limit will not be reconsidered.
    • If the second appeal is received within the 90-day filing limit, Harvard Pilgrim will review the appeal.
    • A determination is made within 30 days following receipt of a second level appeal that is accompanied by the appropriate documentation.

    • Second level outcome

      • If the appeal decision is upheld, the letter outlines the reason(s) for upholding the original decision.
      • If the appeal decision is reversed, the letter explains that the original claim will be adjusted in accordance with payment policy, member agreement and hospital contract.

    Coding and Record Amendment Rules

    Unlisted/unsupported procedure codesmixed
    Unlisted procedure codes or codes lacking supporting documentation should be appealed with relevant operative/office/pathology/anesthesia notes or other medical records.
    Medical record amendment window
    Medical record amendment window30 days from service date
    Effect of amendments after windowAmended records >30 days will not be accepted to defend or increase reimbursement or to reconsider a denied claim
    Official record considerationClinical documentation and physician queries within 30 days are considered the official record for coverage/reimbursement determinations

    Submission Requirements and Filing Deadlines

    Documentation Required

    Initial and second level appeal submission requirements

    Submit a completed Request for Claim Review Form with a copy of the original Explanation of Payment (EOP) and either the HPHConnect claim detail screen or the NEHEN Claim Status Response claim detail screen, plus any supporting documentation that substantiates the appeal.

    • Completed Request for Claim Review Form must accompany all provider appeals; submissions without it will be treated as a first claim submission.
    • Include copy of the original supporting EOP.
    • Include one of: HPHConnect claim detail screen or NEHEN Claim Status Response claim detail screen.
    • Attach supporting documentation relevant to the denied claim.
    Denial Risk

    Appeal filing deadlines

    Ensure appeals are received within the filing limits: initial (Request for Additional Information) appeals no later than 180 days from the original EOP date, and second level appeals no later than 90 days from the date on the original appeal resolution letter; late submissions will not be considered and members cannot be held liable.

    Definitions and Required Forms

    Appeal — definition
    DefinitionAn appeal submitted in response to a claim originally denied for additional information or lacking supporting documentation.
    Common examplesFirst time claim denied for additional information; unlisted procedure code submitted without supporting documentation; codes denied for missing operative/anesthesia/pathology/office notes.
    PurposeTo request reconsideration when denial was due to missing or insufficient documentation
    Request for Claim Review Form — definition
    Required formAll provider appeals must be submitted with a completed Request for Claim Review Form; absence will result in the submission being treated as a first claim submission.
    Consequences of omissionClaims submitted without the form will be treated as a first submission and may result in denial.
    Policy Summary
    Payerharvard pilgrim health care
    PolicyRequest for Additional Information Appeals
    Policy CodePolicy N/A
    Change TypeAdministrative updates
    Effective DateN/A
    Last ReviewJan 1, 2023
    Next Review DateN/A
    Key ActionSubmit a completed Request for Claim Review Form with the original EOP, an HPHConnect or NEHEN claim detail screen, and supporting documentation.
    SourceLink
    On This Page
    Appeal Review CriteriaCoding and Record Amendment RulesSubmission Requirements and Filing DeadlinesDefinitions and Required Forms
    • Initial appeals: received no later than 180 days from the original EOP date.
    • Second level appeals: received within 90 days of the date on the original appeal resolution letter.
    • Appeals received after the applicable filing limit will not be considered.
    Denial Risk

    Medical record amendment restriction

    Do not submit retrospectively amended medical records or physician queries beyond 30 days from the service date; such amended documentation will not be accepted to defend or increase reimbursement or to support reconsideration of a previously denied claim.

    • Harvard Pilgrim will not accept medical records or physician queries amended over 30 days from the service date.
    • Clinical documentation considered is the official record as reviewed within the 30-day window.
    Accompanying itemsAppeals should include a copy of the original EOP, HPHConnect or NEHEN claim detail screen, and supporting documentation.