Harvard Pilgrim credentialing is not limited to simply submitting an application. The entire credentialing process for healthcare providers involves selecting the appropriate application channel, creating a CAQH ProView account, signing the contract, and gaining committee approval. Moreover, you must meet the standard requirements and avoid potential reasons for delays when getting credentialed with Harvard Pilgrim. Both individual physicians and expanding groups must understand the process for successful in-network participation.
Founded by physicians more than 50 years ago, Harvard Pilgrim Health Care merged with Tufts Health Plan in 2021 to create Point32Health (parent company), which is a non-profit health and well-being organization.
Having a Harvard Pilgrim contract as a healthcare provider in New England guarantees you have access to a large pool of members (nearly 900,000). But first, applicants must complete two important milestones: credentialing & enrollment.
Harvard Pilgrim provider credentialing ensures the insurance company knows your qualification details. On the other hand, enrollment will add you to their network of providers and enable listing and payments. Simply put, once credentialed and accepted as an in-network provider, you will be able to deliver care services to Harvard Pilgrim plan members and bill the company for reimbursements.
Harvard Pilgrim credentialing and enrollment requires applicants to prepare for more than just the simple process. It involves a step-by-step process that often leads to application errors if mishandled.
A Step-by-Step Guide to the Harvard Pilgrim Credentialing Application
Applicants can complete the credentialing by following these steps:
1. Identify Your Provider Track
Applicants credentialing with Harvard Pilgrim can choose from three tracks based on their medical speciality. This includes medical professionals (MD, DO, DPM, oral surgeons), ancillary providers, and behavioral health professionals.
Each track has dedicated Harvard Pilgrim credentialing forms, and applicants must submit them to the payer’s Provider Processing Center. The submission details can be found on the network page, and applicants should verify them each time before beginning credentialing.
2. Create your CAQH ProView Profile
Harvard Pilgrim advises beginning the Harvard Pilgrim credentialing process through CAQH ProView (which is the central repository where providers maintain their credentialing information).
Affiliations created will be credentialed in HCAS through this platform. Behavioral health credentialing instructions also require applicants to submit their application through CAQH with the plan’s application form.
3. Get your Signed Agreement
The process of getting credentialed with Harvard Pilgrim begins when you sign an agreement either with the plan or with any Harvard Pilgrim contracted organization like the group. However, Rhode Island is exempt from this requirement.
4. Await Committee Decision
Credentialing cannot take place without all documents being submitted. The credentialing team will notify you by email in case some documents are missing. Moreover, clinicians are not authorized to provide service to Harvard Pilgrim members until they are credentialed.
5. Get Welcome Letter
You will receive your welcome letter with your network participation effective date after signing an agreement and becoming an ‘approved’ provider. In case you require any updates during the process, you may get status calls from the Provider Service Center at 1-800-708-4414.
Harvard Pilgrim Credentialing Requirements
Each provider type at Harvard Pilgrim requires its own form. Therefore, always use the checklist associated with your track. There are a few things in common to most Harvard Pilgrim credentialing applications:
- Fully completed and attested CAQH ProView Profile.
- License (and the DEA registration, when applicable).
- W-9 (required specifically for behavioral health providers).
- Board certification and educational background.
- Hospital admitting privileges (if applicable).
- Active malpractice insurance and its claim history.
- Data form specific to your track (e.g., the Ancillary Practitioner Data Form for behavioral health).
Facility providers have a somewhat different process. Harvard Pilgrim sends a facility credentialing application when the contracting department instructs so. Facility accreditation from an accredited organization is sufficient and does not require a separate survey.
The Provider Manual also includes specialty-specific provisions, like the credentialed subspecialty of Addiction Medicine. Similarly, it covers re-credentialing details, which are equally important for eligible members.
Challenges in Getting Credentialed with Harvard Pilgrim
Harvard Pilgrim insurance credentialing applicants often face delays due to certain challenges in the process. These may include:
Incorrect Order
Providers assume credentialing occurs simultaneously with contracting. But the Harvard Pilgrim policy requires agreement signing first, so any delay in the contracting process slows down the remaining steps.
Incomplete or Inconsistent Data
Harvard Pilgrim says incomplete data causes delays in application processing. An unattested CAQH profile or an outdated or mismatched address is a common delay trigger.
Uncertain Timelines
Harvard Pilgrim enrollment and credentialing take one to two months (according to most sources). Third-party directories state that the timeline is 60 to 90 days. However, applicants should consider the timeline the insurance company mentions. It is usually the best-case scenario, and it helps avoid assumptions.
State-Specific Guidelines
If you join the commercial network of Harvard Pilgrim, you also have to be a part of the Rhode Island Medicaid network (Tufts Health RITogether). In other words, you need to meet additional requirements. Therefore, applicants should verify the details before beginning the Harvard Pilgrim credentialing process.
Post-approval Configuration
Approval does not mean you can start billing. According to the Credential Network Payer Directory, applicants must undergo a separate Electronic Remittance Advice (ERA) enrollment, which may take some weeks. Thus, applicants should educate themselves regarding the requirements now.
Best Practices for Harvard Pilgrim Insurance Credentialing
Harvard Pilgrim provider enrollment and credentialing can be easier if applicants adopt some best practices. Some recommended practices include:
Review CAQH before Applying
Applicants should review all sections, upload updated documents, and test their attestation. If the attestation expires, it can delay the review process even if it is almost complete.
Send Documents At Once
Harvard Pilgrim requests that you return all documents at once. The review process may be delayed due to partial submissions.
Ensure Consistent Information
Applicants should ensure their names, addresses, tax ID numbers, and NPI numbers are consistent across their CAQH profile, W-9, and application forms.
Maintain A Status Log
Constant monitoring of Harvard Pilgrim credentialing application status is important. Therefore, you must document your submission dates, contact persons, and their responses. It will also help you when appeals are required.
Wait Before Booking Members
Schedule members in the Harvard Pilgrim plan after your effective date is confirmed in writing. Services provided to patients before confirmation may not be covered by the insurer.
Make Information Updates Quickly (If Required)
According to Harvard Pilgrim’s manual, applicants should update enrollment information early. Remember, credentialing is not a one-time process. Thus, re-credentialing must be performed every three years (or more often for facilities under contract).
Let MediBillMD Handle Harvard Pilgrim Credentialing
Harvard Pilgrim credentialing is easy but detailed and time-consuming. Applicants can instead use that time to attend to patients. MediBillMD’s medical insurance credentialing services assist applicants throughout the process.
We help applicants with CAQH registration and application submission, status follow-up, and re-credentialing reminders.
