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NETWORK OPERATIONS & CARE DELIVERY MANAGEMENT-RESOURCES
HARVARD PILGRIM HEALTH CARE-PROVIDER MANUAL A.60 March 2021
Changing Provider Enrollment Information
Requirement All changes to provider enrollment must be made on a
prospective basis. It is highly recommended that you use the
Provider Change Form that outlines the required information and
will help to expedite your request. The same procedures apply
whether participation is with commercial, Medicare or Medicaid
products. However, supplemental information may be required for
providers participating in Medicare or Medicaid products.
Provider Number Guidelines The following guidelines apply to
provider numbers: • A clinician with only one tax identification
(Tax ID) number can only have one provider number. • A clinician or
group practice with more than one Tax ID number participating in
more than one local care
unit (LCU) must be enrolled in the Harvard Pilgrim claims system
with a separate provider number for each Tax ID/LCU
relationship.
• PCPs who have multiple provider numbers can only carry one
member panel regardless of the number of provider IDs.
• Specialists with more than one Tax ID number who participate
in more than one LCU must be enrolled in the Harvard Pilgrim claims
system with a separate provider number for each Tax ID/LCU
relationship.
• Providers are enrolled in Harvard Pilgrim’s provider database
consistent with their National Provider Identifier (NPI) and
business relationships they establish with facilities,
organizations, and clinicians included in the Harvard Pilgrim
network.
• Facility and ancillary providers who have subparted by
specialty or location, must notify Harvard Pilgrim of each NPI that
will be submitted to Harvard Pilgrim by email at
[email protected].
Local Care Unit (LCU) Changes
Provider changes related to LCU affiliation include any one or
combination of: • Adding an LCU and provider number • Terminating
from an LCU • Changing an LCU • Terminating from Harvard
Pilgrim
Notification Requirement
In all cases, a minimum of 60 days written notice to Harvard
Pilgrim is required. To the extent that any provision of this
Harvard Pilgrim Health Care manual is inconsistent with any
provision of your contract with Harvard Pilgrim Health Care, the
terms of the contract shall control. For all CT Providers:
• For any termination of a Participating Provider or Agreement,
the Plan and/or Participating Provider must provide at least ninety
(90) days’ written notice to the other party prior to either the
Plan removing a Participating Provider from its network or the
Participating Provider leaving the Plan’s network.
• The Participating Provider or Entity/Hospital/LCU shall
provide the Plan with a list of Plan Members who have been treated
within the last twelve (12) months by the Participating Provider
not later than thirty (30) days of issuing or receiving notice of
termination.
Changes Not Related to LCU Affiliations
Changes not related to LCU affiliation may include any one or
combination of: • Practice address or practice name1 • Billing
address • Close member panel • Addition or change to tax
identification number (TIN)1
mailto:[email protected]
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NETWORK OPERATIONS & CARE DELIVERY MANAGEMENT-RESOURCES
HARVARD PILGRIM HEALTH CARE-PROVIDER MANUAL A.61 March 2021
• Correct Harvard Pilgrim demographic information errors •
Change practice model to concierge style
Notification Requirement In all cases, 30 days written
prospective notice to Harvard Pilgrim is required (except concierge
style — 90 days required).
Medicare and/or Medicaid Participants
If you participate in our Medicare or Medicaid products and are
making a change to your provider enrollment information, please
notify us of your participation in the Medicare and/or Medicaid
products. Harvard Pilgrim’s Provider Change Form includes fields to
note: your participation, National Provider Identified (NPI), TIN,
Medicare and Medicaid numbers and LCU name (if applicable). If your
practice is a messenger model, we will require additional
documentation to confirm the participation status of individual
practitioners. Please make certain that your change request
includes this information. Additionally, if you are part of a LCU
in which only a portion of providers participate in the Medicare or
Medicaid program, please confirm your participation with LCU
leadership.
1Submission of a new W-9 form is required with practice name
change and/or tax identification number change.
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Harvard Pilgrim Health Care—Provider Manual A.62 March 2021
Provider Change Form
(continued)
*Current Provider Information *Section Required
Provider group practice name: E-mail to:
[email protected]
Fax to: 866-884-3843
Mail to: Harvard Pilgrim Health Care
Attn: Provider Processing Center
1600 Crown Colony Drive
Quincy, MA 02169
Provider group practice email address: United Behavioral Health
Providers:
www.providerexpress.com
800-888-2998Provider last name:
Provider first name: Healthways Providers:
www.healthways.com
800-327-3822NPI#: Individual group
PTAN# (if applicable):
Tax ID #:
Provider type (check all that apply):
PCP Specialist Dual Hospitalist
Moonlighter/Covering only Ancillary/Allied/Mid-Level
Locum Tenens
Is your facility handicap accessible?
yes No
Street: City:
State: Zip: Phone:
Indicate changes being submitted (check all that apply):
Demographic change (name, address, NPI, prac-tice status)
LCU change Terminations
These changes apply to: Commercial Medicare Advantage
Indicate documents included:
w9 (required for any billing change)
Provider roster (required for changes impacting entire
group)
other
COMPLETE ALL APPLICABLE INFORMATION. INCOMPLETE SUBMISSIONS MAY
BE RETURNED UNPROCESSED.
NOT FOR NEW PROVIDERS.
PLEASE COMPLETE THE APPLICABLE SECTIONS BELOW TO UPDATE YOUR
INFORMATION.
Does the provider offer telehealth ( i.e. office visits as well
as virtual visits)?
yes No
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Harvard Pilgrim Health Care—Provider Manual A.63 March 2021
Section I: Demographic Change — 30 Day Notice Required
Effective date:
New provider name:
Last name:
First name:
old provider name:
Last name:
First name:
Enter new additional addresses below: Addresses to be updated
(please select one of the following actions):
Terminate location for this provider entirely from Harvard
Pilgrim Health Care Provider Directory
Provider to remain affiliated with this location but suppressed
from listing in Harvard Pilgrim Provider Directory
Provider name: Provider name:
Address Type: Primary Secondary
Can patients make appointments to see this provider at this
location?
yes No
Billing Mailing
Address type: Primary Secondary
Billing Mailing
group name: group name:
Address line 1: Address line 1:
Address line 2: Address line 2:
City: City:
State: Zip: State: Zip:
Phone: Phone:
Enter new additional addresses below: Addresses to be updated
(please select one of the follow-ing actions):
Terminate location for this provider entirely from Har-vard
Pilgrim Health Care Provider Directory
Provider to remain affiliated with this location but suppressed
from listing in Harvard Pilgrim Provider Directory
Provider Change Form
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Harvard Pilgrim Health Care—Provider Manual A.64 March 2021
Provider Name: Provider Name:
Address Type: Primary Secondary
Can patients make appointments to see this provider at this
location?
yes No
Billing Mailing
Address type: Primary Secondary
Billing Mailing
group Name: group Name:
Address line 1: Address line 1:
Address line 2: Address line 2:
City: City:
State: Zip: State: Zip:
Phone: Phone:
NPI (Please contact the Provider Service Center at 800-708-4414
if adding NPI for a subpart.)
New Corrected
Practice Status (May be impacted by contract terms and follow-up
may be required.):
Accepting new patients
Close panel to all new members, but keep existing panel
Concierge practice (90 day notice required)
other (Please specify):
Section 2: LCU Change — 60 Day Notice Required
Effective date:
Name of new or additional LCU:
Add only
Name of current LCU to be terminated (if appli-cable):
Name of new or additional hospital affiliation:
Add only Add & term
Name of current hospital affiliation to be terminated
(if applicable):
New or additional provider tax ID #: Tax ID # to be closed (if
applicable):
New or additional provider payee #: Payee # to be closed (if
applicable):
New or additional specialty or provider type change:*
*Please submit HCAS form for those specialties or provider types
that require credentialing.
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Harvard Pilgrim Health Care—Provider Manual A.65 March 2021
Section 3: Terminations — 60 Day Notice Required
Effective date:
reason for Termination (select one):
resigned Deceased Practice closed
retired Moved out of state other:
Provider transferred to (group name):
*Section 4: Contact Information — (Contact person submitting
information) *Section Required
Name: Title:
Phone: Email:
Date of submission:
A HPHC Prov Change Form-Info_03112021A Provider Change
Form-Info.EXT_031121
Provider group practice name: Provider group practice email
address: Provider last name: Provider first name: Text1:
Individual: Offgroup: OffPTAN if applicable: Tax ID: PCP:
OffSpecialist: OffIs your facility handicap accessible: OffDual:
OffHospitalist: OffMoonlighterCovering only: OffLocum Tenens:
OffAncillaryAlliedMidLevel: OffDoes the provider offer telehealth:
OffStreet: City: State Zip: Text2: Phone: Demographic change name
address NPI prac: OffLCU change: OffTerminations: Offw9 required
for any billing change: OffProvider roster required for changes
impacting: Offother: Off1: Commercial: OffMedicare Advantage:
OffEffective date: New provider name: Text3: First name: Text4:
Enter new additional addresses below 1: Terminate location for this
provider entirely from: OffProvider to remain affiliated with this
location: OffProvider name: Provider name_2: Primary: OffSecondary:
OffPrimary_2: OffBilling: OffSecondary_2: OffMailing: Offyes_2:
OffBilling_2: OffNo_2: OffMailing_2: Offgroup name: group name_2:
Address line 1: Address line 1_2: Address line 2: Address line 2_2:
City_2: City_3: State: Zip: State_2: Zip_2: Phone_2: Phone_3: Enter
new additional addresses below 1_2: vard Pilgrim Health Care
Provider Directory: OffProvider to remain affiliated with this
location but: OffProvider Name: Provider Name_2: Primary_3:
OffSecondary_3: OffPrimary_4: OffBilling_3: OffSecondary_4:
OffMailing_3: Offyes_3: OffBilling_4: OffNo_3: OffMailing_4:
Offgroup Name: group Name_2: Address line 1_3: Address line 1_4:
Address line 2_3: Address line 2_4: City_4: City_5: State_3: Zip_3:
State_4: Zip_4: Phone_4: Phone_5: New: OffCorrected: OffAccepting
new patients: OffClose panel to all new members but keep existing
panel: OffConcierge practice 90 day notice required: Offother
Please specify: OffEffective date_2: Name of new or additional LCU:
Add only: OffText5: Name of new or additional hospital affiliation:
Add only_2: OffAdd term: OffText6: New or additional provider tax
ID: Tax ID to be closed if applicable: New or additional provider
payee: Payee to be closed if applicable: New or additional
specialty or provider type change: Effective date_3: resigned:
OffDeceased: OffPractice closed: Offretired: OffMoved out of state:
Offother_2: OffText7: Text8: Name: Title: Phone_6: Email: Date of
submission: Button9:
