Clear Form
Ancillary Contracting Information Form
Harvard Pilgrim Health Care requires information about your facility/organization in order to fully evaluate your
application to become a participating provider and join our network. The information requested below is necessary
as part of the Harvard Pilgrim contracting process for those providers seeking to obtain in-network status with Harvard Pilgrim, as well as for existing providers to provide up to date information during renegotiations or to document status changes due to mergers or acquisitions.
MA and RI Providers
Please submit to Harvard Pilgrim Health Care, Ancillary Contracting via fax at 617-509-0211 or mail to:
1600 Crown Colony Drive, Quincy, MA 02169
ME, NH and VT Providers
Please submit to Harvard Pilgrim Health Care, Ancillary Contracting via fax at 603-656-9565 or mail to:
650 Elm Street, Seventh Floor, Manchester, NH 03101
CT Providers
Please submit to Harvard Pilgrim Health Care of CT, Ancillary Contracting via fax at 860-757-6901 or mail to:
185 Asylum Street, Second Floor, Hartford, CT 06103
Date:
New Provider
Existing Provider (attach any additional pertinent information not found below)
Please check your facility/organization specialty (please check all that apply):
Acute Rehab Facility
Early Intervention
Laboratory
Ambulance
Family Planning
Radiation Therapy Facility
Ambulatory Surgical Center
Genetics
Radiology/Diagnostic Imaging:
CT
MRI
PET
Ultrasound
Assisted Reproductive Technology
Hospice
Skilled Nursing Facility
Cardiac Monitoring
Home Care
Sleep Laboratory
Dialysis
Home Infustion
Urgent Care
DME
Hyperbaric Oxygen Therapy
Other
Facility/Organization Information
Physical Location (Location where services are rendered, if applicable):
(If you have additional physical locations, please attach a separate list including address, phone, contact name,
TIN, NPI and Medicare Certification Number for each location.)
Facility Name:
Street:
City:
Suite #
State:
County:
Telephone #:
Contact (name and title):
Fax #:
Languages Spoken:
Zip:
Referral telephone # (if different from above):
Email address:
Website address:
Tax Identification Number:
Does your facility bill under any other TIN?
Yes
No
(If yes, please attach a separate list of Tax ID #s, payment names and addresses.)
National Provider Identification Number:
Does your facility bill under any other NPI?
Yes
No
(If yes, please attach a separate list of NPI #s, payment names and addresses.)
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Ancillary Contracting Information Form
Is your facility/organization Medicare Certified?
Yes
No
If yes, Medicare #:
Business address (For notification purposes)
Legal business name:
Title of person who notices should be addressed to:
Street:
Suite #:
City:
State:
County:
Telephone #:
Contact (name and title):
Fax #:
E-mail address:
Zip:
Payment/remittance address
Payment name (Name should appear exactly as on 1099 forms and claim forms):
Billing/agent name (if applicable):
“Remit to” street:
Suite #:
City:
State:
County:
Telephone #:
Contact (name and title):
Fax #:
E-mail address:
Zip:
Accreditation and Certification Information (please check all that apply):
Acute Rehabilitation Facility
Faciity accreditation:
JCAHO
Other:
Please attach a list of the physicians/clinicians who provide anesthesia, laboratory, pathology, and/or radiology
services referred to or provided in conjunction with your operation (please provide name, address, TIN, NPI,
and phone number). These physicians/clinicians must participate in the Harvard Pilgrim network.
Please provide name of ambulance provider used for non-emergent transports:
Ambulance:
Types of Transport Service:
Service Area:
Ambulatory Surgical Center
Facility accreditation:
AAASF
AAAHC
JCAHO
Other:
Do you bill:
Facility only
Global (facility and professional)
Please indicate what type of procedures are performed at your ASC (e.g. orthopedic, endoscopy, colonoscopy,
eye, etc.):
Please attach a list of the physicians/clinicians who provide anesthesia, laboratory, pathology, and/or radiology
services referred to or provided in conjunction with your operation (please provide name, address, TIN, NPI,
and phone number). These physicians/clinicians must participate in the Harvard Pilgrim network.
Assisted Reproductive Technology
Facility accreditation:
AAAHC
JCAHO
Other:
Please attach a list of the physician/clinicians who provide anesthesia, laboratory, pathology, and/or radiology
services referred to or provided in conjunction with your operation (please provide name, address, TIN, NPI,
and phone number). These physicians/clinicians must participate in the Harvard Pilgrim network.
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Ancillary Contracting Information Form
Cardiac Monitoring:
Dialysis:
DME (Please note, the MA/RI networks are currently closed to new providers.)
Please describe the specialty services that your organization currently provides, including all unique services
e.g., standard DME, oxygen, respiratory therapy, orthotics, prosthetics, expanded capacity beds, vents, wound
care, wig, etc. Please attach a list if necessary.
Early Intervention: (Please provide a summary of available child services.)
Family Planning:
Genetics
Facility accreditation:
Do you bill:
CLIA
Facility only
JCAHO
Other:
Global (facility and professional)
Hospice
Facility accreditation:
JCAHO
Other:
Do you own or operate a separate general inpatient or residential hospice facility?
Yes (Please provide name)
No
Please indicate which hospitals you have agreements with for General Inpatient Hospice Care.
Home Care
Facility accreditation:
JCAHO
Other:
JCAHO
Other:
Home Infusion
Facility accreditation:
Hyperbaric Oxygen Therapy
Facility accreditation:
CLIA
JCAHO
Other:
Please attach a list of the physician/clinicians who provide anesthesia, laboratory, pathology, and/or radiology
services referred to or provided in conjunction with your operation (please provide name, address, TIN, NPI,
and phone number). These physicians/clinicians must participate in the Harvard Pilgrim network.
Laboratory
Facility accreditation:
CLIA
JCAHO
Other:
Radiation Therapy
Facility accreditation:
Do you bill:
JCAHO
Global Only
Other:
Professional Only
Technical Only
Radiology/Diagnostic Imaging
Facility accreditation:
Do you bill:
JCAHO
Global Only
Other:
Professional Only
Technical Only
Please indicate if any of your facilities are mobile units:
Please list MDs who will be interpreting the images at your facility:
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Ancillary Contracting Information Form
Skilled Nursing Facility
Facility accreditation:
JCAHO
Other:
Please attach a list of the physician/clinicians who provide anesthesia, laboratory, pathology, and/or radiology
services referred to or provided in conjunction with your operation (please provide name, address, TIN, NPI,
and phone number). These physicians/clinicians must participate in the Harvard Pilgrim network.
Please provide name of ambulance provider used for non-emergent transports:
Sleep Laboratory
Facility accreditation:
Do you bill:
CLIA
Global Only
JCAHO
AASM
Professional Only
Other:
Technical Only
Urgent Care
Type of license:
Facility accreditation:
JCAHO
Other:
JCAHO
Other:
Ultrasound Imaging
Facility accreditation:
Do you bill:
Global Only
Professional Only
Technical Only
Signatory Authority: To allow us to draft the agreement with the current information, please provide the
name and title of the person authorized to execute (sign) the Harvard Pilgrim agreement.
Please print the name of the person authorized to sign the Agreement:
Please print the title of the person authorized to sign the Agreement:
Claim Information (please check all that apply):
Do you submit claims via:
How do you submit claims to Harvard Pilgrim?
UB04/837I
CMS 1500/837P
Paper
EDI, if yes, do you submit through:
HPHConnect
Other, please identify:
Participating Clinicians (for New Hampshire Providers Only)
In the state of New Hampshire only, if you are a Provider for the following services: ART, Family Planning,
Sleep Lab or Radiology, please complete the following:
Please attach a list of participating clinicians who provide direct care (e.g., MD, PA, DO, NP, CRNA, CNM (does
not include clinical support, i.e., RNs), include name, degree, specialty, TIN, NPI, and date of birth.
NOTE: Please ensure you include all independently practicing clinicians.
Ancillary Contracting Information Form; revised April 2017
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