We’re pleased to announce that this month marks the launch of a combined Point32Health provider newsletter, Insights and Updates for Providers, which will deliver news and information for the legacy plans Harvard Pilgrim Health Care and Tufts Health Plan in one handy place.
Point32Health began utilizing Optum RX as the pharmacy benefit manager for all lines of business as of Jan. 1, 2023 and streamlined utilization management for pharmacy and medical drugs. Keep the following in mind when requesting authorization for Harvard Pilgrim and Tufts Health Plan members.
Harvard Pilgrim Health Care and OncoHealth are implementing a step therapy/preferred product strategy for a number of drug classes, effective for dates of service beginning April 1, 2023 for Harvard Pilgrim Commercial members.
As of April 1, 2023, Harvard Pilgrim’s Commercial and Stride (HMO)/(HMO-POS) Medicare Advantage plans will no longer use OncoHealth for radiation oncology medical management.
We’re pleased to launch our new integrated Provider Training and Events webpage, a one-stop-shop replacing the training pages on our legacy provider websites. You’ll find it easier than ever to view our training offerings and sign up for a session.
Beginning April 1, 2023 for Harvard Pilgrim members, oral enteral formulas must be obtained through a contracted durable medical equipment provider, rather than at a retail pharmacy in order for them to be covered.
Effective for dates of service beginning April 1, 2023, Tufts Health Plan is insourcing claims pricing and processing for home infusion services for Tufts Health Plan Commercial, Tufts Medicare Preferred and Tufts Health Plan Senior Care Options.
Effective April 1, 2023, Tufts Health Together–MassHealth MCO Plan and ACPPs will be utilizing MassHealth’s Unified Formulary for pharmacy medications and for select medical benefit drugs, and pharmacy coverage and criteria for Tufts Health Together consequently will mirror that of MassHealth.
Beginning March 1, 2023, AIM Specialty Health (Harvard Pilgrim and Tufts Health Public Plans’ genetic/genomic and molecular diagnostic testing services utilization management vendor) will be known by a new name: Carelon Medical Benefits Management.
Point32Health would like to offer some reminders to provide clarity around the correct billing practices for vision claims for Harvard Pilgrim Health Care and Tufts Health Plan members, to help ensure that these claims are reimbursed appropriately.
Federal regulations require that providers who render services for Medicaid members are screened by and enrolled with the appropriate state Medicaid agency. If you have not yet completed this enrollment/screening process for your applicable patients, please do so.
As a reminder, when billing Harvard Pilgrim and Tufts Health Plan members for services that are delivered through the Psychiatric Collaborative Model of Care, also referred to as Collaborative Care Model (CoCM), it’s important to use the correct procedure codes.
Tufts Health Plan has updated the notification requirement for acute behavioral health services updated from two to three business days for Tufts Health Plan Massachusetts Commercial products, Tufts Health Together, Tufts Health Unify and Tufts Health SCO.
Please refer to this chart to review updates to pharmacy prior authorization programs applicable to Harvard Pilgrim Health Care and Tufts Health Plan products.
Providers and office staff can refer to the following chart to review changes and updates to Point32Health’s Medical Necessity Guidelines (MNGs), information about newly developed MNGs, and more.
In accordance with recent action by the Rhode Island Executive Office of Health and Human Services, Tufts Health Plan is issuing a rate increase retroactive for dates of service on or after July 1, 2022 for certain pediatric claims for Tufts Health RITogether.
In alignment with a rate increase implemented by the Rhode Island Executive Office of Health and Human Services, Tufts Health Plan will automatically reprocess any claims submitted for personal care services between July 1, 2022 and Jan. 25, 2023.