When requesting authorization for pharmacy or medical benefit drugs for USFHP members, please utilize the prior authorization forms provided on the USFHP website. PromptPA is not currently available for USFHP members.
Insights and Updates for Providers
Harvard Pilgrim is no longer using OncoHealth for radiation oncology medical management for Commercial and Stride members. In an effort to more closely align the provider experience across Point32Health products, we’re also implementing some changes for Tufts Health Plan products.
If your behavioral health patient has migrated or is migrating from a Tufts Health Plan to a Harvard Pilgrim Commercial product prior to July 1, 2023 and you do not currently participate in the Optum/United Behavioral Health network, please request a single case agreement to provide care seamlessly.
MassHealth is launching a new value-based sub-capitation accountable care organization model beginning April 1, and two Tufts Health Together plans have been selected to participate in the ACO program. The ACO model emphasizes investment in primary care, behavioral health, and pediatric care.
As previously communicated and 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.
Want to know about the latest integration updates? Have questions about behavioral health changes coming in 2023? Need guidance on navigating our provider websites? Register for one of our April webinars for support in working with Point32Health and a forum to get your questions answered!
As of Jan. 1, 2023, Point32Health provides coverage for breastfeeding supplies including storage bags for breast milk (HCPCS code K1005) for certain products, with a quantity limit of 300 bags per three-month reimbursement period.
As a reminder, we recommend electronic claims submission for the fastest processing. For paper claims submission, some of our mailing addresses have changed over the past year. Please remember to use our latest addresses when mailing paper claims.
Federal regulations require that providers who serve Medicaid members — including those who participate in Tufts Health RITogether, Tufts Health Together – MassHealth MCO Plan and Accountable Care Partnership Plans, Tufts Health Senior Care Options, and Tufts Health Unify — are screened by and enrolled with the appropriate state Medicaid agency.
We’ve developed an integrated Point32Health Fraud, Waste, and Abuse Payment Policy, in an effort to offer information pertaining to Harvard Pilgrim Health Care and Tufts Health Plan policies and procedures streamlined in one comprehensive document.
Harvard Pilgrim and Tufts Health Plan members are entitled to receive full coverage for preventive care services, with no cost-sharing responsibility, when these services are rendered by an in-network provider. Refer to the PPACA/preventive services documentation referenced in this article for more details.
As a reminder, MassHealth All Provider Bulletin 305 explains billing practices for newborn children of all MassHealth members and applies to Tufts Health Together and Unify plans. These guidelines require that providers bill for newborn services separately and not under the mother’s member ID number.
As part of our ongoing review of performance specifications, we revised the behavioral health performance specifications identified in this article, applicable to certain Tufts Health Plan products, effective April 1, 2023.
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.
This chart identifies code updates to Point32Health and National Imaging Associates, Inc.’s (NIA’s) medical necessity review program, which are effective June 1, 2023 and intended to align coverage and criteria for the Harvard Pilgrim and Tufts Health Plan products included in the program.
MassHealth recently announced the following updates to the MassHealth Unified formulary, effective June 5, 2023.