Currentharvard pilgrim health carePolicy N/A

CMS requirements for Harvard Pilgrim Stride SM Medicare Advantage plans

Summarizes CMS-mandated coverage and operational requirements that Harvard Pilgrim's Stride SM Medicare Advantage benefit plans must meet; affects Harvard Pilgrim Medicare Advantage plan administration and provider networks.

Policy Summary

Payerharvard pilgrim health care

PolicyCMS requirements for Harvard Pilgrim Stride SM Medicare Advantage plans

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionEnsure provider network and service availability meet CMS access and operational standards, including 24/7 access and required preventive services without cost-sharing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24/7access by phone or office hours

No waiting periodspre-existing condition exclusions

Includedambulance coverage

Coveredrenal dialysis outside area

No cost-sharingpreventive services

CMS-mandated Coverage and Operational Standards

CMS-required Coverage and Operational Standards

Harvard Pilgrim Medicare Advantage (Stride SM) plans must meet the following CMS requirements:

CMS Plan Requirements: Offer a provider network that allows sufficient access to covered services per CMS standards; provide benefits consistent with professionally recognized standards of health care; make covered services available 24/7 via office hours or telephone; impose no waiting periods or exclusions for pre-existing conditions; cover 911-dispatched ambulance services when other transport would endanger health; cover maintenance and post-stabilization care related to emergency medical conditions; cover renal dialysis services for members temporarily outside the plan service area; include CMS-required preventive services (e.g., screening mammography, influenza vaccinations) without referral and without member cost-sharing.

Each listed item is a CMS requirement summarized from the document.

This policy document does not enumerate clinical service exclusions. Instead, it summarizes the CMS-required coverage and operational standards that Harvard Pilgrim’s Stride SM Medicare Advantage plans must meet. The emphasis is on plan-level obligations—network access, benefit availability, preventive service coverage, emergency and post‑stabilization care, dialysis access when members are temporarily outside the service area, and related CMS operational requirements—rather than on listing specific services that are excluded from coverage.

Provider Requirements and Operational Notes

Policy Summary

Payerharvard pilgrim health care

PolicyCMS requirements for Harvard Pilgrim Stride SM Medicare Advantage plans

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionEnsure provider network and service availability meet CMS access and operational standards, including 24/7 access and required preventive services without cost-sharing.

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.

Prior Authorization

Prior authorization — not specified

The policy does not specify any prior authorization requirements for covered services; no explicit prior authorization rules are stated in the document.

Step Therapy

Step therapy — not addressed

This document does not address step therapy; no step therapy requirements or protocols are specified.

Documentation Required

Operate in a CMS-compliant network and meet professional standards

Providers must operate within a network that provides sufficient access to covered services per CMS standards and must provide benefits consistent with professionally recognized standards of health care.

Offer a provider network that allows sufficient access to covered services according to CMS standards [422.112(a)(1)].
Provide benefits in a manner consistent with professionally recognized standards of health care [422.504(a)(3)(iii)].

Denial Risk

Network/access noncompliance may trigger denials or corrective action

Failure to provide sufficient network access or to make covered services available as required by CMS standards could lead to denial, compliance action, or other corrective measures.

Network must allow sufficient access to covered services per CMS [422.112(a)(1)].
Covered services must be available 24/7 via office hours or telephone service [422.122(a)(8)], and lack of availability could trigger compliance issues.

Policy Background and Scope

This document provides a concise summary of the Centers for Medicare & Medicaid Services (CMS) requirements that govern benefit design and operational standards for Harvard Pilgrim’s Stride SM Medicare Advantage plans. It outlines the plan obligations to: offer a provider network that provides sufficient access to covered services per CMS standards; deliver benefits consistent with professionally recognized standards of health care; make covered services available 24 hours a day, seven days a week via office hours or telephone; impose no waiting periods or pre‑existing condition exclusions; cover 911‑dispatched ambulance services when other transport would endanger health; cover maintenance and post‑stabilization care related to emergency medical conditions; cover renal dialysis for members temporarily outside the plan service area; and include CMS‑required preventive services (for example, screening mammography and influenza vaccination) without referral and without member cost‑sharing.