INSURER FILING GUIDE
Harvard Pilgrim Health Care
Use this public information to prepare your packet, then confirm the route on the insurer's own page.
AT A GLANCE
Claim facts
| Member form | Health Care Reimbursement Claim Form Number: 1234919024-1023 Revision: Not published by the insurer Open the insurer form |
|---|---|
| Portal upload | YES |
| Portal path | Forms library > Health Care Reimbursement Claim Form > Complete online |
| Mail address | Harvard Pilgrim Health Care, P.O. Box 699183, Quincy, MA 02269 |
| Fax | Not published by the insurer |
| Attachments | Member full name and address; birth field (label as printed); plan ID; member signature; provider or facility name and address; TIN or NPI; diagnosis description, diagnosis code, or ICD-10 code; date of service; CPT code or brief illness or injury description; charge; proof of payment; other insurance information |
| Deadline | Within one year of date of service |
| Outcome and status | Secure member account or Harvard Pilgrim app > Claims; monthly Activity Summary |
| Processing time | Not published by the insurer |
| Caveats | A provider or facility claim form may be included but is not required; CMS-1500 is not named. The form says a photographic copy of the authorization is as valid as the original but does not address typed or electronic signatures. HMO non-plan care is covered only in listed exceptions; PPO and POS terms differ; state-specific external review and employer self-funded terms differ; Medicare and Medicaid excluded |
STEP BY STEP
Filing steps
Source: https://www.harvardpilgrim.org/public/docs/health-care-reimbursement-claim-form-instructions---pdf
Read date: 10-09-2026
Research steps
- Use the Health Care Reimbursement Claim Form for medical, hospital, and behavioral health out-of-network services. Harvard Pilgrim says one combined form has applied since November 1, 2023. https://www.harvardpilgrim.org/public/site/city-of-marlborough/forms-library
- Gather proof of service and proof of payment. The claim requires member and provider details, diagnosis, service dates, procedure or CPT information, charges, payment proof, and other-insurance information. https://www.harvardpilgrim.org/public/docs/health-care-reimbursement-claim-form-instructions---pdf
- In the forms library, under Get reimbursed for covered medical, hospital and behavioral health services, select Complete online. https://www.harvardpilgrim.org/public/site/city-of-marlborough/forms-library
- Complete the secure HPHConnect Member Reimbursement form and submit the required support. The screen is behind login and was not opened. https://hphconnect.harvardpilgrim.org/asp/healthbank/harvardpilgrim/secure/Member/MemberReimbursement.asp
- Leave the separate assignment box and assignment signature incomplete when payment should not go directly to the provider. https://www.harvardpilgrim.org/public/docs/health-care-reimbursement-claim-form-instructions---pdf
- Submit within one year of the service date. Check Claims in the secure member account or Harvard Pilgrim app; the Activity Summary also reports processed claims. https://www.harvardpilgrim.org/public/transparency and https://www.harvardpilgrim.org/public/commonly-asked-questions
- NOT PUBLISHED: accepted file types, size, attachment count, document packaging, submission confirmation, processing time, and typed or electronic-signature acceptance. https://www.harvardpilgrim.org/public/site/city-of-marlborough/forms-library
Filing facts
- Portal upload: YES
- Portal: HPHConnect secure member account
- Portal path: Forms library > Health Care Reimbursement Claim Form > Complete online
- Mail address: Harvard Pilgrim Health Care, P.O. Box 699183, Quincy, MA 02269
- Fax: NOT PUBLISHED
- Attach: Member full name and address; birth field (label as printed); plan ID; member signature; provider or facility name and address; TIN or NPI; diagnosis description, diagnosis code, or ICD-10 code; date of service; CPT code or brief illness or injury description; charge; proof of payment; other insurance information
- File types: NOT PUBLISHED
- File size limit: NOT PUBLISHED
- Maximum files: NOT PUBLISHED
- One file or separate files: NOT PUBLISHED
- Confirmation: NOT PUBLISHED
- Status check: Secure member account or Harvard Pilgrim app > Claims; monthly Activity Summary
- Processing time: NOT PUBLISHED
- Member deadline: Within one year of date of service
- Deadline basis: YES: state, product, and employer handbook control
- Mental health route: The same Health Care Reimbursement Claim Form and online link cover medical, hospital, and behavioral health services; the insurer says the forms were combined on November 1, 2023
Confirm the address, fax number or portal path on the insurer's own claims page before you send; read on 10-09-2026.
Read on 10-09-2026 from https://www.harvardpilgrim.org/public/docs/health-care-reimbursement-claim-form-instructions---pdf. Confirm the address, fax number or portal path on the insurer's own claims page before you send.