Effective for dates of service beginning Jan. 1, 2026, Point32Health is making a number of policy and coverage updates pertaining to applied behavioral analysis (ABA) therapy services, which vary by product. 

We’re replacing our MNG for ABA therapy services for Commercial plans and Tufts Health Direct with the new Applied Behavioral Analysis (ABA) for Commercial Products and Tufts Health Direct MNG. The Applied Behavioral Analysis (ABA) Therapy for Autism Spectrum Disorders: Rhode Island Products MNG will be retired, and the new MNG will apply for Rhode Island Commercial products in addition to those in MA, ME, and NH. 

The policy will utilize InterQual criteria and we’re adopting a number of InterQual SmartSheets for prior authorization review. 

Down syndrome coverage for Commercial, Direct, and Together

For Harvard Pilgrim and Tufts Health Plan Commercial products in Massachusetts only — including Tufts Health Together — in accordance with recent legislative guidance, we will cover ABA therapy services for members who have a singular diagnosis of Down syndrome. (An additional diagnosis of autism spectrum disorder will not be required for coverage of these patients.) The above-referenced MNG for Commercial and Direct outlines covered ICD-10 diagnosis codes for Down syndrome, and similar updates are in development for the MNG specific to Tufts Health Together, which will leverage criteria from MassHealth. 

To reflect this change, our Autism Services Payment Policy has also been revised and renamed Applied Behavioral Analysis (ABA). 

Coding updates 

For Harvard Pilgrim Commercial plans, HCPCS codes H0031 and H0032 will no longer be covered, and CPT code 0362T will require prior authorization for Tufts Health Direct. 

Requesting authorization

To request ABA prior authorization for Harvard Pilgrim Health Care Commercial, Tufts Health Direct, and Tufts Health Plan Commercial members, please continue to utilize the state’s Standard Form for Applied Behavioral Analysis Services Prior Authorization Requests. For Tufts Health Together members, please use Point32Health’s updated Applied Behavioral Analysis Prior Authorization Form. 

As a reminder, we encourage providers to submit prior authorization requests electronically, in which case the prior authorization form must be uploaded with the request. If, however, you prefer to submit a prior authorization request by fax, please complete the form and fax it to the appropriate number below. 

  • Harvard Pilgrim Health Care Commercial members: 800-232-0816
  • Tufts Health Plan Commercial members: 617-673-0314
  • Tufts Health Direct members: 888-977-0776 

(Consistent with Maine regulations, the new MNG for Commercial and Direct is also posted here temporarily.)