Yes. Make sure your admitting physician and the hospital are Harvard Pilgrim participating providers. Then ask your physician to get an authorization from Harvard Pilgrim for the surgery and/or hospital stay. Authorizations from BCBS will not be transferred to Harvard Pilgrim.
If neither the physician nor the hospital are participating providers, please call the Total Assist line at (866) 874-0817.
If your clinician accepts Harvard Pilgrim coverage
You can continue treatment, provided it is a covered benefit. Be sure to call the Behavioral Health Access Center as soon as you enroll with Harvard Pilgrim. Please note that your cost sharing amounts may change depending on your particular plan.
If your clinician does not accept Harvard Pilgrimcoverage
Call the Behavioral Health Access Center at (888) 777-4742 to find out if you are eligible for transitional benefits. Transitional benefits allow you to continue ongoing treatment for a limited time with providers who do not accept Harvard Pilgrim.
You must call the Behavioral Health Access Center to request transitional coverage within 30 days of the effective date of your coverage with Harvard Pilgrim. Otherwise you may not be eligible for transitional benefits.
Prior authorization: If you take a medication that required prior authorization from BCBS, it may require prior authorization from Harvard Pilgrim. To check, visit www.harvardpilgrim.org/rx. Choose “3-Tier Program” and then “Prior authorization required.”
If your medication requires Harvard Pilgrim’s prior authorization, ask your provider to submit a Medication Request Form to our pharmacy benefits manager, MedImpact. Physicians can obtain these forms on the “Providers” section of www.harvardpilgrim.org.
Mail order: If you currently receive mail order prescriptions through Express Scripts:
- Ask your provider to write new prescriptions.
- Send your prescriptions and a completed mail order form to Walgreens Mail Service. Visit www.harvardpilgrim.org/rx for a copy of the mail order form.
Harvard Pilgrim members receive their care from more than 28,000 doctors and other clinicians and 135 hospitals throughout the region.
To find out if your doctor participates with Harvard Pilgrim:
- Call your doctor
- Call our Member Services department at 1-888-333-4742
- Use our Find a Doctor tool
If you need help finding a new doctor, we can help you find one based on factors that are important to you. Call our Member Services department, or use “Find a Doctor” on our Web site to search for a doctor who meets your needs.
If you select an HMO plan, you and any dependents you may be covering on your policy will be asked to select a primary care provider when you enroll. You can each have a different PCP.
Your PCP will provide or arrange for all the health services you need–treating you when you’re sick, and administering preventive screenings, routine check-ups and immunizations. If you need care from a specialist, your PCP will give you a referral. PPO members are not required to select a PCP.
For HMO members: Although there are thousands of physicians who take care of Harvard Pilgrim members, your PCP will refer you to a specialist affiliated with his or her own practice. If you need to visit a cardiologist, for example, your doctor will refer you to someone in a local medical practice or hospital with which he or she is affiliated. PCPs typically develop strong working relationships with particular specialists. This helps the doctors collaborate more effectively their patients’ care and helps ensure excellent communication, appropriate choice of treatment and higher-quality care.
Your PCP may occasionally make a referral to a physician outside his or her usual network of specialists, but only if the expertise needed to handle a particular case is not available from a specialist affiliated with his or her own practice. Whenever you need specialty care, feel free to ask your doctor about the referral process and if he or she recommends a certain specialist.
For PPO members: No. Referrals are not necessary in the PPO option.
Harvard Pilgrim has established a unique program to help new members discuss specific issues or concerns regarding their specialized medical care prior to their enrollment on the Plan. Our Clinical Transition staff can help find the resources to meet individual medical needs and if appropriate, can have a plan for continuing your care already in place by the time you join.
We can also help with HMO members whose current providers are not participating with Harvard Pilgrim. Our staff will provide assistance with planning a safe and appropriate transition of care based on the medical needs of each individual member.
For assistance please call our TotalAssist line at (866) 874-0817.
For HMO members: Yes. When you’re away, you’re covered for virtually any care you may need if you become sick or injured. Harvard Pilgrim covers unexpected or unforeseen care (e.g. for earaches, flu, etc.) when you’re traveling outside the state in which you live.
For PPO members: Yes. If you seek care for covered services while traveling, they will be covered at the in-network level when you visit participating providers and at the out-of-network level when you visit non-participating providers. Outside of Massachusetts, Maine, New Hampshire and Rhode Island, Harvard Pilgrim participating providers include the Private Healthcare Systems (PHCS) network of nearly 500,000 providers and 3,700 facilities across the United States.
Harvard Pilgrim covers all medical emergencies (e.g., heart attack, stroke, choking, loss of consciousness or seizures). Just go to the nearest emergency facility or call 911 or another local emergency number. If you are hospitalized, call your PCP and Harvard Pilgrim within 48 hours, or as soon as you can (or ask someone to do this for you).
Questions?
Call the TotalAssist line at (866) 874-0817.