We announced in last month’s newsletter that 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 for providers in our service area other than Maine. Please note that we will be implementing this program for Maine providers providing care for Harvard Pilgrim Commercial members effective for dates of service beginning Dec. 1, 2025.
As of these effective dates, 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 To access these policies and review details, visit the Payment Policy section of our Provider website. |
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- Cervical Cancer Screening
- Prostate Biopsy Specimen Analysis
- Diagnostic Testing of Iron Homeostasis & Metabolism
- Immunohistochemistry
- Biomarker Testing for Autoimmune Rheumatic Disease
- Hepatitis Testing
- Pediatric Preventative Screening
- Helicobacter Pylori Testing
- Biochemical Markers of Alzheimers Disease and Dementia
- Bone Turnover Markers Testing
- Diagnosis of Vaginitis
- Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing
- Therapeutic Drug Monitoring for 5-Fluorouracil
- Identification of Microorganisms 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 Cancer Screening and Testing
- Human Immunodeficiency Virus (HIV) Testing
- Salivary Hormone Testing
- Serum Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases
- Urinary Tumor Markers for Bladder Cancer
- Testing of Homocysteine Metabolism-Related Conditions
- Biomarkers for Myocardial Infarction and Chronic Heart Failure
- Pancreatic Enzyme Testing for Acute Pancreatitis
- General Inflammation Testing
- Diagnostic Testing of Common Sexually Transmitted Infections
- β-Hemolytic Streptococcus Testing
- Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing
- Gamma-glutamyl Transferase Testing in Adults
- Colorectal Cancer Screening
| - Diabetes Mellitus Testing
- Prostate Specific Antigen (PSA) Testing
- Testosterone
- Flow Cytometry
- Prenatal Screening (Nongenetic)
- Venous and Arterial Thrombosis Risk Testing
- Celiac Disease Testing
- Thyroid Disease Testing
- Cardiovascular Disease Risk Assessment
- Diagnosis of Idiopathic Environmental Intolerance
- Epithelial Cell Cytology in Breast Cancer Risk Assessment
- Testing for Diagnosis of Active or Latent Tuberculosis
- Testing For Alpha-1 Antitrypsin Deficiency
- Immune Cell Function Assay
- In Vitro Chemoresistance and Chemosensitivities Assays
- Nerve Fiber Density Testing
- Metabolite Markers for Thiopurines
- Diagnostic Testing of Influenza
- Testing 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
- Onychomycosis Testing
- Coronavirus Testing in the Outpatient Setting
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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.