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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyHarvard Pilgrim WC claim rules & filing limits | O…
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    Currentharvard pilgrim health carePolicy N/A

    Workers' Compensation (WC) Claims

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    Governs billing and submission procedures when a claim is related to a workers' compensation (WC) accident and describes responsibilities for providers and claim filing timelines; applies to Harvard Pilgrim members except those in Choice or Choice Plus through Passport Connect.

    Policy Summary
    Payerharvard pilgrim health care
    PolicyWorkers' Compensation (WC) Claims
    Policy CodePolicy N/A
    Change TypeAdministrative clarifications (non‑material)
    Effective DateN/A
    Last ReviewJan 1, 2024
    Next Review DateN/A
    Key ActionFollow Harvard Pilgrim referral, prior authorization and prior approval policies when Harvard Pilgrim is secondary for services to be reimbursed.
    SourceLink
    POLICY UPDATE CHANGES

    Removed Connecticut retroactive denial information.

    Clarified New Hampshire retroactive denial applicability.

    90 daysstandard WC claim filing limit after WC denial

    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.

    120 days
    Maine filing limit when coordinating with primary insurer
    180 daysNew Hampshire filing limit for retroactive primary denial
    No balance billNo balance billing
    2Mailing addresses

    Workers' Compensation Claim Submission Criteria

    WC claim submission criteria

    Requirements and criteria for submission of workers' compensation (WC)–related claims to Harvard Pilgrim when the WC carrier has denied the claim or when coordination with a primary insurer applies.

    Provider billed the workers' compensation (WC) carrier first.
    If the WC carrier denied the claim, attach a copy of the WC denial letter when submitting the claim to Harvard Pilgrim.

    Providers may call Harvard Pilgrim to verify receipt of the WC denial letter.

    ALL of the following

    • Member name
    • Member identification number
    • Date of WC accident
    • Name and address of WC carrier

    ALL of the following

    • Standard: Claim must be submitted to Harvard Pilgrim within 90 days of the date posted on the WC denial letter.

    • Claims will be denied if any of the following apply:

      • Submitted beyond 90 days from the date on the WC denial letter
      • Submitted with no date on the WC denial letter
      • Submitted without notification from the WC carrier that the claim has been denied

    State-specific exceptions

    • Maine: When coordinating with a primary insurer, the filing limit is 120 days from the date the primary insurer processed the claim or retroactively denied a previously paid claim as indicated on the primary insurer's Explanation of Benefits (EOB).
    • New Hampshire: When Harvard Pilgrim is secondary and the primary policy was retroactively terminated, the filing limit is 180 days from the date the primary insurer retroactively denied a previously paid claim as indicated on the primary insurer's EOB. (Does not apply if the primary carrier terminated under normal circumstances.)

    ALL of the following

    • Payment from the WC carrier is payment in full; no balance bill can be submitted to Harvard Pilgrim or its members.
    • If Harvard Pilgrim pays or denies a claim and is later informed it is related to a WC accident, an insurance liability recovery investigator will determine the primary payer and adjust the claim accordingly.
    Submission addresses and correspondence

    Claims and correspondence should be sent to the appropriate Harvard Pilgrim P.O. Box addresses as provided in provider materials.

    Claim Filing Timeframes and Limits

    Claim filing timeframes — WC
    Standard filing timeframeSubmit claim within 90 days of the date on the WC denial letter; claims received beyond 90 days will be denied.
    Maine exceptionWhen coordinating with a primary insurer, filing limit is 120 days from the date the primary insurer processed the claim or retroactively denied a paid claim as shown on the primary insurer EOB.
    New Hampshire exceptionWhen Harvard Pilgrim is secondary and the primary policy was retroactively terminated, filing limit is 180 days from the date the primary insurer retroactively denied a paid claim as shown on the primary insurer EOB.

    Provider Responsibilities When Harvard Pilgrim Is Secondary

    Prior Authorization

    Follow Harvard Pilgrim referral/prior authorization rules when secondary

    When Harvard Pilgrim is secondary, providers must follow Harvard Pilgrim's referral, prior authorization, and prior approval policies for services to be reimbursed by Harvard Pilgrim as the secondary payer.

    Key Definitions and Billing Rules

    WC denial letter
    DefinitionA WC denial letter is the written notification from the workers' compensation carrier indicating the claim has been denied; providers must attach a copy when submitting the bill to Harvard Pilgrim.
    Required when submitting to Harvard PilgrimClaims related to a WC accident must include the WC denial letter; claims without a denial date or without notification of denial may be denied if submitted after filing limits.
    Verification optionProviders may call Harvard Pilgrim to verify that a WC denial letter has been received.
    Payment in full / No balance billing
    Payment is payment in fullPayment from the workers' compensation carrier is considered payment in full; Harvard Pilgrim will not accept additional billing for that amount.
    No balance billing to member or Harvard Pilgrim
    Policy Summary
    Payerharvard pilgrim health care
    PolicyWorkers' Compensation (WC) Claims
    Policy CodePolicy N/A
    Change TypeAdministrative clarifications (non‑material)
    Effective DateN/A
    Last ReviewJan 1, 2024
    Next Review DateN/A
    Key ActionFollow Harvard Pilgrim referral, prior authorization and prior approval policies when Harvard Pilgrim is secondary for services to be reimbursed.
    SourceLink
    On This Page
    Workers' Compensation Claim Submission CriteriaClaim Filing Timeframes and LimitsProvider Responsibilities When Harvard Pilgrim Is SecondaryKey Definitions and Billing Rules
    Providers may not submit a balance bill to Harvard Pilgrim or to its members for amounts covered by the WC carrier.
    Claim adjustment processIf Harvard Pilgrim pays or denies a claim and later learns it is related to a WC accident, an insurance liability recovery investigator will determine the primary payer and adjust the claim accordingly.