Currentharvard pilgrim health carePolicy N/A

Request for Additional Information Appeals

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

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

90 dayssecond level appeal filing limit

30 daysdecision timeframe

P.O. Box 699183mailing address

Choice/Choice Plusexcluded products

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.

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 omission