Commonly asked questions

• HMO members: You will need a referral from your PCP, and you must see a participating specialist.
• POS members: You will need a referral for authorized coverage. If you don’t get a referral or if you choose to go out of network, you will have higher costs.
• PPO members: If you see a participating specialist, your costs will be lower than if you see a non-participating specialist.

Adults with Harvard Pilgrim plans can get a flu shot at no charge at:

• Thier PCP/specialist's office
• CVS MinuteClinics in Massachusetts, Connecticut, New Hampshire and Rhode Island (not covered in other states)
• Pharmacies that participate in MedImpact (age 19 years and older only)
• Massachusetts city/town public clinics coordinated through the Massachusetts Department of Public Health and billed to Harvard Pilgrim Health Care by Commonwealth Medicine
• Public clinics run and billed by New England Nurses (Massachusetts, southern New Hampshire, and parts of Rhode Island)
• Public clinics run and billed by Harvard Pilgrim contracted Home Health Agencies
• Your employer. Check with your Human Resources department to see if your company is offering it

Children coverd on Harvard Pilgrim plans can get a flu shot at no charge at:

• Their pediatrician's office
• City/town flu clinics in schools or public clinics for children and adults

Always call ahead to confirm schedules and availability, and make sure the provider or clinic accepts Harvard Pilgrim insurance and will submit a claim. Always bring your ID card with you.

Yes. A colonoscopy is an ACA preventive service. It’s covered at no cost to members when received from a provider who is part of your Harvard Pilgrim network.

As part of Federal Health Care Reform (FHCR) Women’s Preventative Coverage, the following breast pumps and related supplies are covered with no cost sharing.

• A4281 Tubing for breast pump, replacement
• A4282 Adapter for breast pump, replacement
• A4283 Cap for breast pump bottle, replacement
• A4284 Breast shield and splash protector for use with breast pump, replacement
• A4285 Polycarbonate bottle for use with breast pump, replacement
• A4286 Locking ring for breast pump, replacement
• E0602 Breast pump, manual, any type — this is a purchase-only item
• E0603 Breast pump, electric (AC and/or DC), any type
• E0604 Breast pump, hospital grade, electric (AC and/or DC), any type, 3-month rental

Your insurance plan also covers comprehensive lactation support, counseling and the costs of renting breastfeeding equipment. The following items are not covered: nursing pads, gel pads, nipple cream and milk storage bags.

Find out by calling your doctor or search our online directory.

Yes. Please check out our tips for members who live outside of our service area. 

Under the Affordable Care Act, also known as the ACA or the PPACA, there are designated services that are considered preventive and must be covered with no cost to members. You receive preventive services whether you are well or sick. They are benchmarks to assess your health, and they determine if you need more specialized care.

See a list of covered preventive services (www.healthcare.gov)

As a Harvard Pilgrim member, you are covered for urgent care at retail clinics, urgent care clinics and other convenient options.

Learn about options when you need urgent care

Find a provider

If we receive a claim for a service that indicates a member received care after an accident, we send the member a questionnaire. The completed questionnaire helps us determine if another insurance company should pay because a third party (a person or business) was responsible for the accident. We can then process claims correctly. The questionnaire should be submitted within 60 days of receipt.

Download the questionnaire

A secure online account helps you manage your health plan through a wide variety of resources. You can review claims and authorizations, track your deductible if you have one, use fitness and wellness tools, and more.

Members age 13 and older must create their own individual accounts even if they are on their parent’s plan.

Create a secure online account

Forgot username/password

Multifactor authentication help

Being able to view family members’ information in your Harvard Pilgrim online account depends on a few things. 

Per federal (HIPAA) and state laws, adult members cannot view other adult family members’ information without their consent. If you want another adult on your plan to be able to see your information, you can change your family permissions. 

The family permissions feature also gives parents access to minor children's online information if the parents and children are covered on the same policy.  

After they create their online accounts, dependents between 13 and 17 years old can give a parent who is not on the same policy access to their Harvard Pilgrim account by sending us: 

• A Designated Representative form

• Any type of legal documentation that identifies the parent as their legal guardian 

If your child is 12, they will not be able to create an account and you will not be able to view their personal health record or claims information. 

Per federal (HIPAA) and state laws, what parents can see and the functions they have access to depends on a child's age and the type of service.  

State laws require health plans to have additional safeguards and protections in place regarding certain types of sensitive health information (e.g., abortion, behavioral health, reproductive health and sexually transmitted infections) for minors between the ages of 12 and 17. To comply with those state requirements, Activity Summaries and referral and authorization details are not available to parents for children between 12 and 17 years old. 

For children up to 11 years old, parents can view all information, including their child’s: 

• Personal health record 

• Claims 

• Activity Summary 

• Referrals and authorizations 

For children 12 to 17 years old, parents can view their child’s: 

• Personal health record 

• Claims that are unrelated to sensitive health information 

You can contact Member Services if you have questions about your child's health plan information. Please remember that by law, we may still be unable to give you access to a minor's personal health information for certain diagnoses or treatment.  

Harvard Pilgrim provides members with a monthly Activity Summary, also known as an explanation of benefits or EOB. It lists the services you received, highlighting how we've processed claims for medical services you've received. It will help you keep track of the progress you've made to satisfy your financial responsibility, including deductible and out-of-pocket amounts. The Activity Summary is not a bill, but it will let you know if you owe your provider money. A new Activity Summary will be posted each month to your secure member account. We will e/mail one to you when you’re responsible for a deductible, coinsurance or an amount not covered by your plan.  

Members can also View claims as they are received by providers and track their processing status.  

Check your Schedule of Benefits in  My Plan Documents in your secure online account. This document is specific to your plan and tells you what is covered and what you pay for services.

Every plan is different. Log into your secure online account to find out if your plan offers a reimbursement.

Learn details about how the fitness reimbursement works

It depends on the type of plan you have. If you have an HMO or POS plan, you must choose a PCP. PPO members are not required to choose a PCP, but it’s typically recommended.

You can change your PCP by logging into your secure online account, or calling Member Services at (888) 333-4742.