Providers

Claim Forms

Standard Medical Claim Form

Standard Dental Claim Form

Appeal Forms

Health Plans General Provider Appeal Form (non HPHC)

Harvard Pilgrim Provider Appeal Form and Quick Reference Guide

Request for Network Exception 

 Network Exception Request Form

Precertification Forms

Please note: Precertification requirements vary by plan. Please contact HPI Provider Services or log in to Access Patient Benefits and review your patient's plan description for a full list of services requiring precertification. Precertification forms below are only for plans using AchieveHealth^® CMS in New England and Halifax. Please verify the correct precertification vendor prior to submitting forms; unverified precertifications will be returned.

AchieveHealth^® Precertification List

 Standard Precertification Request

If your patient's plan requires Precertification for a service or procedure listed below, please complete the Standard Precertification Request form in addition to the applicable form below.

 Bariatric Surgery Precert Questions (Mandatory)

Chemotherapy/Cancer Treatment Medication
 Chemotherapy Support Drugs

Pediatric/Adult Formula

Some forms on this page are in PDF format and require Adobe Reader to open.