Point32Health is offering a reminder of the change we’ve previously announced pertaining to claim adjudication for ancillary and supporting services when they are billed in connection with services that require prior authorization and that authorization is not obtained.
The change, which we’ve outlined in previous issues of Insights and Updates for Providers, is currently in effect for most Point32Health products as of July 1, 2026, and will take effect on Sept. 1, 2026 for Harvard Pilgrim Health Care Commercial.
If a claim is denied due to lack of prior authorization, untimely authorization, or failure to meet medical necessity criteria, any related ancillary or supporting services or procedures associated with the denied service, whether billed on the same claim or on separate claims, will also be denied. This includes medications used to support the procedure requiring prior authorization. For Tufts Health Public Plans and Senior Products, such denials will be denoted using the code UMD1254 (Supporting service denied due to no authorization) along with Claim Adjustment Reason Code (CARC) A1 (Claim/Service denied) and Remittance Advice Remark Code (RARC) N19 (Procedure code incidental to primary procedure). An equivalent code for Commercial products is in development.
Exceptions for which this updated denial process will not apply include:
This updated claims adjudication process also does not apply to claims submitted by Maine-contracted providers for services requiring prior authorization for fully insured members with plans issued in Maine. These claims will continue to be processed following a medical necessity review in accordance with Maine insurance statute (24-A MRS §4304).