Insights and Updates for Providers

August 2023

Update on Behavioral Health insourcing

Harvard Pilgrim Health Care Commercial

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.

Billing reminder for pelvic floor therapy

All products

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.

Update: Prior authorization on insulin pumps and home infusion

Harvard Pilgrim Health Care Commercial

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

All products

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

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

Tufts Health RITogether

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

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

Tufts Health Public Plans

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

All products

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

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

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

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

Tufts Health RITogether

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 Commercial | Tufts Health Plan SCO | Tufts Medicare Preferred HMO | US Family Health Plan (USFHP)

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 

Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Health Plan Senior Products

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

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.