Health Plans Inc Appeals Address and How to File an Appeal

Appeals for plans administered by Health Plans, Inc. (HPI) go to the same Westborough post office box as claims. What differs is the form, the attention line and the deadline. Providers and members follow separate tracks, so find yours below. For the general claims mailing address, see our Health Plans Inc claims address page.

Provider appeals: forms and packet checklist

HPI publishes two provider appeal forms. Pick the one that matches the member's network:

• HPI provider appeal form (non-HPHC network): for members whose plan uses a network other than Harvard Pilgrim. The form states that the filing limit of the prevailing network applies.
• HPI provider appeal form and quick reference guide (HPHC network): for HPI members who use the Harvard Pilgrim network. It covers specific denial types, including filing limit denials and referral denials.

Both versions warn that incomplete appeal submissions are returned without being processed. Build the packet like this:

1. One appeal form per claim. Do not bundle several claims under one form.
2. A copy of the EOP (explanation of payment) showing the denial you are appealing.
3. The claim form (CMS-1500 or UB-04) for the claim in question.
4. Supporting documentation for the denial type. A prior-authorization denial needs the authorization evidence; a timely filing denial needs proof of the original submission date; a duplicate denial needs whatever shows the claims are different.
5. Mail it to PO Box 5199, or to any appeal address printed on the member's card or denial notice, and keep a dated copy of everything.

Provider appeal deadlines

HPI's general provider pages do not publish one appeal deadline for every plan. Two specific rules are documented:

A note on that second row: Harvard Pilgrim's manual tells providers that HPI appeals follow HPI's own procedures on HPI's website. So treat the 90-day rule as the network's policy that HPI's HPHC-network form points back to, not as an HPI-wide rule. Our timely filing limits guide covers how those network rules apply.

Member appeals: your rights and the steps

Most HPI plans are self-funded employer plans, which fall under the federal ERISA claims rules (government and church plans can follow different rules). Under the Department of Labor's claims procedure regulation, a group health plan must give you at least 180 days after you receive a denial to file an appeal. Your plan can allow longer, and the Summary Plan Description (SPD) is where the actual deadline is written.

1. Read the denial notice closely. It must explain the reason and the plan provision behind it, and it describes how to appeal.
2. Ask for your claim file if you need it. Federal rules let you request, free of charge, the documents and records relevant to your claim.
3. Complete HPI's member appeal form, available on HPI's member forms page or your plan's HPI website.
4. Attach evidence. A letter from your doctor explaining medical necessity, records, itemized bills, and a copy of the denial.
5. Mail it to the Member Appeals Department, PO Box 5199, Westborough, MA 01581, unless your denial notice gives a different address. Keep copies and the mailing date.

How long the plan has to decide

Plans with two levels of internal appeal split those windows between the levels. If the internal appeal is denied, many plans must offer an independent external review; the final denial letter explains whether that applies and how to request it.

When an appeal is the wrong tool

Not every problem needs an appeal. If a claim was rejected electronically, it was never accepted, so fix it and resubmit (see the payer ID and electronic claims guide). If you made a coding or billing error, a corrected claim is usually faster than an appeal. Appeals are for disagreeing with a decision HPI actually made on a claim it accepted.