Insights and Updates for Providers

June 2023

System updates for our provider network

All products

We continue our work in restoring our core Harvard Pilgrim Health Care systems and encourage providers and office staff to visit our System Update for Providers FAQ for the latest information.

Behavioral Health Payment Policy update

Tufts Health Plan Commercial

Our new Behavioral Health and Substance Use Disorder Payment Policy, effective July 1, 2023 for Tufts Health Plan commercial members, details reimbursement for medically necessary services rendered in inpatient, outpatient and acute residential settings and includes billing guidelines.

Join us for a personalized claims consultation

All products

Point32Health is pleased to announce that we will be opening the doors to our Canton office this summer to host providers for claims consultations. The event will be an opportunity for providers to meet with our Provider Relations team, who will be available as a resource to support you by answering questions you may have about claims.

Reminder: Tufts Health Together Accountable Care Organizations for 2023

Tufts Health Together—ACOs

As previously announced, two Tufts Health Together plans have been selected by MassHealth to participate in a new value-based sub-capitation accountable care organization (ACO) beginning April 1, 2023. Read more for some reminders and notable information about the plans.

One Care training requirement and resources for Tufts Health Unify

Tufts Health Unify

We offer convenient training resources in the Tufts Health Unify Provider Trainings section of the Tufts Health Plan provider website, in support of Executive Office of Health and Human Services and CMS requirements that providers complete training on the One Care program.

Tufts Health Public Plans initial paper claims address change

Tufts Health Public Plans

Please be aware that the address for Tufts Health Public Plans initial paper claim submissions is changing. Starting August 1, 2023, initial paper claims for both Massachusetts and Rhode Island Public Plans should be sent to the address indicated in this article.

NIA vendor program code updates

Harvard Pilgrim and Tufts Commercial | Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Health Plan Commercial | Tufts Health Public Plans

In the April issue of Insights and Updates for Providers, Point32Health announced a number of changes expected to take effect June 1, 2023 in relation to the medical necessity review and prior authorization program that National Imaging Associates, Inc. (NIA) oversees on our behalf for certain procedures.

Telehealth reimbursement for Tufts Health Direct members

Tufts Health Direct

As we announced in previous issues of Insights and Updates for Providers, Point32Health currently reimburses medical services provided via telehealth for our commercial Harvard Pilgrim Health Care and Tufts Health Plan members in Massachusetts, Rhode Island, and Maine at 80% of the in-person rate.

Standard annual eligibility review process returning

Tufts Health Plan SCO | Tufts Health RITogether | Tufts Health Together | Tufts Health Unify

Because the annual renewal process for Medicaid members has resumed, over the next year all Medicaid members will need to have their eligibility re-determined. Please remind your Medicaid patients to complete the renewal process.

2023 Home Care Seasonal Flu Vaccine Fee Schedule

Harvard Pilgrim Health Care Commercial

Updates to Harvard Pilgrim’s standard home care seasonal influenza vaccine fee schedule will take effect on Aug. 1, 2023. To request an updated fee schedule, please call the Provider Service Center at 800-708-4414.

Mindfulness program for providers

All products

Point32Health is pleased to offer our providers access to our Peak Mind Challenge, which features a playlist of twenty brief meditation videos showcasing Dr. Amishi Jha’s mindfulness-based methods to train your attention to improve brain power, mood, and performance.

Point32Health Medical Necessity Guideline updates

Tufts Health Plan Commercial | Tufts Health Public Plans

Review this chart for information on updates to Medical Necessity Guidelines (MNGs) associated with Point32Health’s products

Providers and office staff can refer to the following chart to review information on changes and updates to Medical Necessity Guidelines (MNGs) pertaining to the various products under the Point32Health umbrella.

MassHealth Unified Formulary: medical drug updates

Tufts Health Together

Tufts Health Together–MassHealth MCO Plan and ACPPs now utilize MassHealth’s Unified Formulary for pharmacy medications and for select medical benefit drugs. Effective June 5, 2023, these updates regarding medical drugs and the MassHealth Unified Formulary will apply,

MassHealth Unified Formulary: pharmacy drug updates

Tufts Health Together - MassHealth MCO Plan and ACPPs

MassHealth recently announced the following updates to the MassHealth Unified Formulary, effective July 31, 2023. The table below outlines these changes, which include pharmacy products being added to the MassHealth Drug List, as well as new and updated prior authorization programs.

Pharmacy coverage changes

Harvard Pilgrim Health Care Commercial | Tufts Health Direct | Tufts Health Plan Commercial | Tufts Health Together

Review this chart for updated Pharmacy Medical Necessity Guidelines with changes effective August 1, 2023 for Point32Health’s Pharmacy drug prior authorization program.

Billing updates for Tufts Health Plan providers

All Tufts Health Plan Products

Point32Health would like to keep our providers apprised of a number of updates and reminders related to billing practices for various services and Tufts Health Plan products.

Code update for injectable drugs

Tufts Health Plan MCO/ACO | Tufts Health Unify

Effective for dates of service beginning Aug. 1, 2023, J-codes for injectable drugs will deny when submitted for Tufts Health Unify and Tufts Health Plan MCO/ACO claims without an accompanying quantity, appropriate National Drug Code (NDC) number, and unit of measurement code.