Integration FAQ

What product changes are planned?

We offer a broad range of comprehensive plans that improve the well-being of members and their families, guiding them on their journey to better health outcomes. As part of our integration, Point32Health evalutated the products offered by our Harvard Pilgrim Health Care and Tufts Health Plan brands, and made a decision to integrate some of our products.

What is the plan for Commercial products?

We decided to integrate our Commercial products to offer more innovation, more access, and an even better experience for providers, members, employers, and brokers in our service area. As a result, we have been moving Tufts Health Plan Commercial members to our Harvard Pilgrim Health Care plans.

With these product migrations, certain Tufts Health Plan products will no longer be offered, and comparable Harvard Pilgrim products will be offered to employer group clients and individual members. We will continue to offer our Harvard Pilgrim commercial products in Maine and New Hampshire.

How much progress has been made on Commercial integration?

We have completed much of this work and anticipate that we will have moved all our Commercial accounts, with the exception of the US Family Health Plan by June 2025. Commercial employer group clients and members are being migrated to Harvard Pilgrim products throughout a staggered and thoughtful timeline that began on Jan. 1, 2023. Transitions occur on the health plan renewal date.

How are members and other stakeholders being made aware of these changes?

We are communicating extensively with commercial employer accounts, brokers, and health plan members on these changes. In particular, health plan members are being reminded to look for their new member ID cards and present them when seeking care or services to ensure that eligibility and claims processing are accurate.

Our communications include sending broad-based updates, as well as direct and individual communications to explain changes. These communications are being delivered through a variety of channels: as part of renewal processes, via newsletters, and direct to employer and member updates.

How will I recognize if a member has changed plans?
Every member who has a medical plan change will receive a new member ID card prior to their effective date, as part of our standard open enrollment and renewal processes. Members are always instructed to present any new member ID card that they receive to their providers to ensure accuracy in billings, claims, and payments.

In addition, we encourage your office to check eligibility and benefits using our online provider tools. You can check member eligibility and benefits for Harvard Pilgrim Health Care members using our HPHConnect portal. For more options, refer to the Determining Eligibility Policy in the Harvard Pilgrim Health Care Commercial Provider Manual. To check member eligibility and benefits for Tufts Health Plan members, visit the Tufts Health Plan secure provider portal or refer to the relevant Provider Manual.

If my trading partner sends an eligibility transaction to Tufts Health Plan, but the member is now with Harvard Pilgrim, will I need to resend the transaction?
No, in an effort to minimize eligibility transaction rejections for migrating members and resubmissions, Point32Health is automatically returning eligibility information for migrating members with the correct Plan details. For example, if a request is sent to Tufts Health Plan for a member who recently migrated from Tufts Health Plan Commercial to Harvard Pilgrim Commercial, information returned will note the correct Harvard Pilgrim policy and benefit information. If you utilize a trading partner, please make them aware of this information.

Can I call either Provider Service Center with questions?
Please continue to call the member’s appropriate heritage organization with questions — please refer to the member’s ID card for the Provider Service Center contact information. For example, if for the service date you are inquiring about the member is enrolled in a Harvard Pilgrim Health Care plan, please contact the Harvard Pilgrim Health Care Provider Service Center; if the member is enrolled in a Tufts Health Plan product for that service date, please contact the Tufts Health Plan Provider Service Center.

Will there be any changes to how I bill for service?

You should continue to follow the guidelines for the plan/legacy brand that is in effect for the member at the time of service. Please refer to the appropriate provider website for details on billing and claims submission: Tufts Health Plan provider website or Harvard Pilgrim Health Care provider website.

How will claims that span a member’s migration date appear on my EOPs/835s?
When a service for a migrating member spans the migration date, Tufts Health Plan will pay for services prior to the migration date and Harvard Pilgrim will pay for services on and after the migration date. There is no need for the provider to resend a claim; in an effort to minimize provider disruption, Point32Health is automatically entering the claim into our legacy organizations’ processing systems. However, we want you to be aware that providers will receive 2 Explanations of Payment/835s for spanned claims: one from each legacy organization. While your statements will reflect two different payers and claim numbers, the date of service and total charges will be identical on both statements. You’ll see that each organization will process their portion of the claim and deny the portion that the other legacy organization is responsible for. The EOP/835 will include messaging that says: “Dates of service following migration between THP and HPHC adjudication systems have been denied and transferred to the appropriate system for processing and adjudication. No further provider action needed” or “The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.”

Will existing authorizations be honored for Commercial members transitioning from Tufts Health Plan to Harvard Pilgrim Health Care?

Yes, as part of our commitment to facilitating a seamless transition for members and providers, any existing authorizations for medical and behavioral health services will be valid. This means that providers will not have to submit a duplicate authorization request for the same services/time period for migrating members. The existing authorization will be valid through the expiration date.

Will existing referrals also be honored for Commercial migrating members?

We will honor active, open referrals for members migrating from a Tufts Health Plan Commercial plan to a Harvard Pilgrim Health Care Commercial plan.

What will happen if a Commercial migrating member is currently receiving care management services with Tufts Health Plan?

Care management services are vital to improving patient care by enhancing coordination of care, eliminating duplication, and aiding patients and caregivers in more effectively managing their health conditions. We will transfer medical care management cases from Tufts Health Plan’s care management team to Harvard Pilgrim Health Care’s care management team and will ensure that the member continues to receive care management services.

What will happen if a Commercial migrating member is at an inpatient facility at the time of their plan change?

For patients receiving inpatient care at the time of their plan migration, medical care management services will continue to be provided by the Tufts Health Plan care management team. Upon discharge, the case will be transferred to the Harvard Pilgrim care management team.

What will happen if a commercial migrating member is receiving care from a provider who is not in the Harvard Pilgrim Health Care network?

We are committed to ensuring as little disruption for members and providers as possible. Given the robustness of our networks and similarities in composition, we anticipate that the vast majority of members will be able to continue to see their providers without interruption. In the event that a migrating member is currently in active care with a provider who isn’t in the Harvard Pilgrim Health Care network for their new product, the member can utilize Harvard Pilgrim Health Care’s standard Continuity of Care policy. For more information, please refer to the Continuity of Care/Transitional Care Request Form.

At the end of the Continuity of Care timeframe, options include: the member selecting an in-network provider; the provider can submit for medical necessity review; the provider can discuss becoming a participating provider with network contracting, or if the member is in a PPO product they could continue to see the provider based on out-of-network rules.

What changes occurred for behavioral health?
Point32Health began operating an insourced behavioral health program for Harvard Pilgrim Commercial products and all Tufts Health Plan products on Nov. 1, 2023. Previously, Harvard Pilgrim utilized an outsourced or “carve-out” model in which a vendor managed behavioral health care.  With our insourced program, Point32Health now manages both medical and behavioral health care coverage and programs, including utilization and care management.

When insourcing occurred, Optum continued to provide behavioral health services for Harvard Pilgrim Health Care’s Stride^SM (HMO)/(HMO-POS) Medicare Advantage plan in New Hampshire and will continue to provide services through Dec. 31, 2024, at which time the Stride product will be discontinued. Until then, providers should continue to work directly with Optum for  Stride^SM (HMO)/(HMO-POS) Medicare Advantage members.

Where do providers submit claims?
For Tufts Health Plan members, submit claims to Tufts Health Plan.

For Harvard Pilgrim Commercial members, if you practice in our service area (practicing in MA, ME, NH, RI, VT) bill Harvard Pilgrim directly. If you are an out-of-area provider, please submit out-of-area claims to United Health Shared Services Claims, Payer ID 39026, Group Number 11-123456, PO Box 30783, Salt Lake City UT 84130-0783 (this information is also noted on the back of the member’s ID card).

For Stride Medicare Advantage (HMO/HMO-POS) members, providers should submit electronic or paper claims to Harvard Pilgrim as they do today. For details refer to the Claims Policy in the Stride (HMO)/(HMO-POS) Medicare Advantage Provider Manual or this Quick Reference Guide. We will continue to process claims through the timely submission time frame for Stride, which is 365 days from the date of service.

Filing limit information for all plans is detailed in our Provider Manuals.

I currently see Harvard Pilgrim members through my contract with Optum/UBH but am not contracted with Harvard Pilgrim. How can I ensure I can continue to care for my patient?

When we first insourced our behavioral health program in November 2023, as a transitionary measure, providers who participated in the UnitedHealthcare network were considered in-network for Harvard Pilgrim. Given that our insourced program includes a robust network of providers to meet the behavioral health needs of our members, effective Jan. 1, 2025, these providers will no longer be considered in-network.

If you are not yet a contracted Harvard Pilgrim Health Care provider, you may continue to provide uninterrupted care of members through Harvard Pilgrim’s continuity of care program, which varies by state (90 days for MA, ME, NH members and 365 days for RI members).

The best way to ensure uninterrupted care for your patients is to visit our Join our Network page for information and instructions.

Our Behavioral Health Quick Reference Guide for Providers outlines everything you need to know about working with us to care for Harvard Pilgrim’s Commercial members.

I recently became contracted for Harvard Pilgrim Health Care. Where can I access additional information?

Our welcome packet includes tips for getting started with Harvard Pilgrim, including registering for HPHConnect, signing up to receive our provider newsletter by email, and setting up electronic payment.

How do I become a contracted provider?

We’re pleased that you would like to join our provider network. To get started, visit our Join our Network page for information and instructions.

I’m not sure if I’m contracted with Harvard Pilgrim or not. How can I find out?

For questions on your contracting status, please contact our Provider Service Center for Harvard Pilgrim at 800-708-4414. For more information on contacting us, including the phone numbers for our Provider Service Center by line of business, please visit the  Contact Us page.

What resources are available?

We encourage you to:

• Visit the Point32Health Provider Training page to access user guides and training videos.
• Read our monthly provider newsletter, Insights and Updates for Providers on our provider website or subscribe to receive the newsletter by email.
• Refer to our Provider Manuals for up-to-date guidance on products, programs, policies, and procedures. You’ll find Manuals for all our lines of business on the Point32Health Provider Manual page.