In previous issues of Insights and Updates for Providers, we’ve announced a change 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.
That change took effect for most Point32Health products on July 1, 2026, and is now also in effect for Harvard Pilgrim Health Care Commercial as of Sept. 1, 2026.
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 UMD124: 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). We are exploring the feasibility of developing an equivalent denial code for Commercial products.
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).