Update on Behavioral Health insourcing
We want to provide you with an update on our plans to insource our behavioral health program for Harvard Pilgrim commercial members, which will now be taking place on Nov. 1, 2023.
Insights and Updates for Providers
August 2023
Billing reminder for pelvic floor therapy
As a reminder, Point32Health provides coverage for treatment of pelvic floor disorders. Members are eligible to receive clinical evaluation and physical therapy (PT) as outlined in their plan benefits, and providers should use diagnosis code 090.89 when billing for PT for pelvic floor disorders.
You’re invited: Join us for a personalized claims consultation in Canton
As part of our ongoing commitment to collaborating with our valued provider partners, and building on the success of our July claims consultation, we are hosting another claims consultation in October.
Update: Prior authorization on insulin pumps and home infusion
As part of ongoing efforts to review prior authorization requirements and reduce administrative burden, Harvard Pilgrim Health Care is removing prior authorization requirements for insulin infusion pumps and home infusion administration for commercial members.
Join us for a provider training
Point32Health’s August webinars offer providers the opportunity to ask questions and share feedback while gaining the latest information on products, processes, systems and more. To register, click the links included in this article.
One Care training requirement and resources for 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.
Rhode Island professional fee schedule updates
Beginning Oct. 1, 2023, Point32Health will be updating the Rhode Island Medicaid professional fee schedule we use to determine claims reimbursement for services rendered to Tufts Health RITogether members.
Behavioral Health and substance use disorder tools and resources
Tufts Health RITogether providers have access to several behavioral health and substance use disorder resources. You’ll find information on behavioral health coverage, prior authorization and notification for behavioral health services, resources such as our Provider Manual, and more on the Tufts Health RITogether behavioral health webpage.
Reminder: Public Plans initial paper claims address change
As a reminder, the address for Tufts Health Public Plans initial paper claim submissions changed on August 1, 2023. Initial paper claims for both Massachusetts and Rhode Island Public Plans that were previously sent to P.O. Box addresses in Foothill Ranch, CA, should now be sent to the address identified in this article.
Cell and gene therapy monitoring
For dates of service beginning Oct. 1, 2023, providers are required to comply with long-term monitoring requirements related to cell and gene therapies, including requests for follow-up clinical data and/or attestation of clinical outcome.
Expanded coverage of Community Behavioral Health Centers
Tufts Health Plan commercial members have access to two programs provided by Community Behavioral Health Centers (CBHCs) — Mobile Crisis Intervention (MCI) and Community Crisis Stabilization (CCS) — aimed at increasing access to care and promote community-based treatment options rather than emergency department visits for behavioral crisis intervention.
Billing for specialized Community Support Program services
This article provides an overview of MassHealth’s Community Support Program (CSP) Services, available to members of the Tufts Health Plan Together, Tufts Health Unify, and Tufts Health Plan Senior Care Options products, as well as information about billing and notification requirements.
Claims filing requirement for court-ordered service
For RITogether members, Tufts Health Plan will not require prior authorization for claims for court-ordered mental health/substance abuse services, for dates of service beginning July 1, 2023.
Reminder: P.O. Box changes for referral forms
Tufts Health Plan encourages electronic submission of referrals for greater convenience and a real-time receipt of a referral number. Alternatively, providers may submit outpatient referrals using paper referral forms to the updated mailing addresses identified in this article.
Billing Medicare members for non-covered services
We would like to provide some reminders regarding the steps a contracted provider must take prior to billing members of our Harvard Pilgrim Health Care and Tufts Health Plan Medicare Advantage plans/Senior Products for non-covered services.
Point32Health Medical Necessity Guideline updates
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.
Update on authorization requests for home care and hospice
Effective for dates of service beginning Oct. 1, 2023 for Harvard Pilgrim commercial members, providers must request a new authorization for home care and hospice services that extend beyond the end date of the existing authorization.
Migration to 2023 InterQual criteria
Point32Health utilizes InterQual criteria for clinical authorization review for a number of services. For the Medical Necessity Guidelines listed here, we will be adopting 2023 InterQual SmartSheets to replace the previous versions currently in use.
OncoHealth program update
In a continued effort to reduce prior authorization burden on providers and members, effective Sept. 1, 2023 these drugs will no longer require prior authorization through OncoHealth for oncology indications for members of Harvard Pilgrim’s commercial and Stride Medicare Advantage plans.
Pharmacy coverage changes
Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.
Prenatal vitamin coverage update
Effective for fill dates on or after Jan. 1, 2024, Harvard Pilgrim Health Care Commercial Plans, Tufts Health Plan Commercial Plans and Tufts Health Plan Direct will only cover prescription generic prenatal vitamins on our pharmacy formulary.
Generic inhalers coverage update
Effective Oct. 1, 2023, the identified generic inhaler products will not be covered in the formularies for Harvard Pilgrim Health Care commercial, Tufts Health Plan commercial and Tufts Health Direct. Alternative NDCs for the same drug, and similar agents, are covered on our formularies.
Reminder: Prior authorization for long-acting opioids
As a reminder, Harvard Pilgrim commercial members who are currently taking a long-acting opioid and who have not had a clinical review completed will require authorization on or after Nov. 1, 2023.
MassHealth updates to Unified Formulary
MassHealth recently announced the following updates to the MassHealth Unified Formulary, effective Oct. 2, 2023. The table below outlines these changes, which include pharmacy products and medical drugs being added to the MassHealth Drug List, as well as new and updated prior authorization programs.
JZ modifier now required
In accordance with Centers for Medicare and Medicaid Services (CMS) policy, for dates of service on or after July 1, 2023, Point32Health now requires providers to append modifier JW or JZ when reporting a drug from a single-dose vial or package.
Roadmap for Behavioral Health Reform: Incident and Issue Reporting Portal
Introduced in 2021 and implemented in 2023 by the Commonwealth, the Massachusetts Roadmap for Behavioral Health Reform increases access to mental health and substance use disorder treatment for people across Massachusetts and offers insurance-blind behavioral health crisis services to anyone in the state.