As you know, medical costs have been rising sharply. One area of focus is laboratory services, which account for more than $82 billion annually in the United States. Point32Health is committed to ensuring members have access to medically necessary laboratory services while implementing policies that support appropriate utilization and affordability of care.
As part of these efforts, we are implementing a new laboratory benefit management program for Harvard Pilgrim Health Care Commercial products, effective for dates of service beginning Nov. 1, 2025.*
As of this effective date, we will implement the following new Payment Policies and utilize automated claims edits (post-service, pre-payment) to ensure consistency with the guidelines for laboratory services, tests, and procedures performed in office, hospital outpatient, and independent laboratory locations. Laboratory services provided in emergency rooms, hospital observation, and hospital inpatient settings are excluded from this program.
New Payment Policies for Harvard Pilgrim Health Care Commercial*
Cervical Cancer Screening
Prostate Biopsies
Diagnostic Testing of Iron Homeostasis & Metabolism
Immunohistochemistry
Biomarker Testing for Autoimmune Rheumatic Disease
Hepatitis C
Pediatric Preventative Screening
Helicobacter Pylori Testing
Biochemical Markers of Alzheimers Disease and Dementia
Bone Turnover Markers Testing
Diagnosis of Vaginitis including Multi-target PCR Testing
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing
Therapeutic Drug Monitoring for 5-Fluorouracil
Identification of Micro-organisms by Nucleic Probes
Intracellular Micronutrient Analysis
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies
Serum Marker Panels for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
Oral Screening Lesion Identification Systems and Genetic Testing
Plasma HIV 1 RNA Quantification for HIV-1 Infection
Salivary Hormone Testing
Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases
Urinary Tumor Markers for Bladder Cancer
Testing of Homocysteine Metabolism-Related Conditions
Cardiac Biomarkers for Myocardial Infarction
Pancreatic Enzyme Testing for Acute Pancreatitis
General Inflammation Testing
Diagnostic Testing of Most Common Sexually Transmitted Infections
Hemolytic Streptococcus Testing
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing
Gamma-glutamyl Transferase
Colorectal Cancer Screening
Hemoglobin A1c Diabetes Mellitus Testing
Prostate Specific Antigen (PSA) Testing
Testosterone Testing
Flow Cytometry
Prenatal Screening (Nongenetic)
Venous and Arterial Thrombosis Risk Testing
Celiac Disease
Thyroid Disease Testing
Cardiovascular Disease Risk Assessment
Diagnosis and Management of Idiopathic Environmental Intolerance
Epithelial Cell Cytology in Breast Cancer Risk Assessment
Gamma Interferon Blood Test for Dx of Latent Tuberculosis
Testing For Alpha-1 Antitrypsin Deficiency
Immune Cell Function Assay
Invitro Chemoresistance and Chemosensitivities Assays
Measurement of Thromboxane Metabolites for ASA Resistance
Nerve Fiber Density Testing
Pharmacogenomic and Metabolite Markers for Thiopurines
Diagnostic Testing of Influenza
Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease
Serum Tumor Markers for Malignancies
Evaluation of Dry Eyes
Pathogen Panel Testing
Serum Testing for Evidence of Mild Traumatic Brain Injury
Folate Testing
Urine Culture Testing for Bacteria
Mosquito- and Tick-Related Infections
Avalon Laboratory Procedures Reimbursement Policy
Onychomycosis Testing
Coronavirus Testing in the Outpatient Setting
To access these policies and review details, visit the Payment Policy section of our Provider website. For ease of identification, all the policies listed above begin with “Laboratory” and the name shown on our Payment Policies page (for example, “Laboratory: Colorectal Cancer Screening” and “Laboratory: Hepatitis C). These evidence-based policies are aligned with the latest scientific research to determine the appropriateness of lab testing.
We encourage ordering providers and laboratories that utilize requisition forms and panels to review the new Payment Policies and adjust forms as needed to help avoid ordering and conducting tests that would not be covered.
*This effective date does not apply for Maine providers, as we will announce the program for Maine providers in the October issue of the provider newsletter, consistent with Maine legislative requirements.
Receive Insights and Updates for Providers by email