Insights and Updates for Providers

July 2023

Returning to business as usual

All products

In the wake of the cybersecurity incident we identified on April 17, we have returned our core Harvard Pilgrim Health Care systems, business functions, and tools online and wanted to share an overview of recent announcements.

AbleTo virtual behavioral health program expanded

Tufts Health Direct | Tufts Health Together—MCOs | Tufts Medicare Preferred

AbleTo’s personalized therapy program is now available to Tufts Health Direct, Tufts Health Together-MCO, and Tufts Medicare Preferred members, and will continue to be offered to Harvard Pilgrim Health Care commercial and Stride (HMO/HMO-POS) Medicare Advantage members.

Update to Integra’s DMEPOS network: Senior Products

Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

Integra will soon begin to assume management of the DMEPOS provider network for Point32Health’s Senior Products, starting on July 1, 2023 for Tufts Medicare Preferred and Tufts Health Plan Senior Care Options, and on Sept. 1, 2023 for Harvard Pilgrim Stride (HMO)(HMO-POS) Medicare Advantage.

Reminder: 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.

FDA-unapproved product coverage update

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

Effective immediately, any products listed on the Harvard Pilgrim Health Care commercial, Tufts Health Plan commercial, and Tufts Health Direct formularies that have not been approved by the FDA will be excluded from coverage, in alignment with the information listed on our Evidence of Coverage documents and Member Handbooks.

Join us for a provider training

All products

Point32Health’s July webinars offer providers the opportunity to ask questions and share feedback while gaining the latest information on products, processes, systems and more — and registering is easy!

MassHealth Unified Formulary updates

Tufts Health Together

We’re sharing some updates regarding medical benefit drug coverage and the MassHealth Unified Formulary, which will apply for Tufts Health Together beginning July 31, 2023.

Point32Health Medical Necessity Guideline updates

All 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.

Pharmacy coverage changes

Harvard Pilgrim and Tufts Commercial | Tufts Health Direct | Tufts Health Plan Commercial | Tufts Health RITogether

Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.

Coordination of medical and behavioral health care

All products

At Point32Health, we believe collaboration and communication between primary care physicians and behavioral health care providers are pivotal to quality patient care, helping to minimize adverse medication interactions, allowing for better management of treatment, and improving follow‐up for patients with behavioral health and other medical conditions.

Updates and reminders for FUH and IET HEDIS measures

All products

Point32Health would like to highlight some information and reminders that may help support you in your efforts to adhere to the guidelines and standards of care set forth by the Follow-Up After Hospitalization for Mental Illness (FUH) and Initiation and Engagement of Substance Use Disorder Treatment (IET) HEDIS measures.

Clinical discharge summaries for psychiatric and SUD treatment

All products

As a reminder, psychiatric and substance use disorder treatment facilities are required to submit discharge summaries within 24 hours of member discharge from an inpatient, residential treatment, or partial hospitalization program. This article outlines requirements for Point32Health members.

Screening for depression in the primary care setting

All products

There are several depression screening tools available for use in the primary care setting, which Point32Health recommends as a starting point for diagnosis and coordination of follow-up care, and we also offer helpful resources and information.

MassHealth guidance on provider-to-provider e-consults

Tufts Health Plan Senior Care Options | Tufts Health Together - MassHealth MCO Plan and ACPPs | Tufts Health Unify

Point32Health has updated our applicable Tufts Health Plan systems, as well as the Tufts Health Plan Evaluation and Management Professional Payment Policy, to reflect MassHealth guidance on coverage of provider-to-provider e-consults.

Update for acute inpatient facility readmissions

Tufts Health Direct | Tufts Health RITogether | Tufts Health Together | Uncategorized

Please be aware that for dates of service beginning Sept. 1, 2023, the readmission policies for DRG facilities for Tufts Health Direct, Tufts Health Together, and Tufts Health RITogether will be expanded to apply to providers reimbursed at a case rate.

Reminder of telehealth billing requirements

Tufts Health Plan Senior Care Options | Tufts Health Together | Tufts Health Unify

We’re offering some reminders and clarifying information on billing for telehealth services for Tufts Health Plan Senior Care Options, Tufts Health Together, and Tufts Health Unify members.

Changes to ambulatory surgical center payments

Tufts Health Plan Senior Care Options | Tufts Medicare Preferred HMO/PPO

Effective for dates of service beginning Sept. 1, 2023, CPT code 99070 (supplies and materials provided by the physician or other qualified healthcare professional) will no longer be separately reimbursed for ambulatory surgical centers (ASCs).