Insights and Updates for Providers

September 2023

Important behavioral health insourcing information

Harvard Pilgrim Health Care Commercial

We’re pleased to be moving ahead with behavioral health insourcing effective Nov. 1, 2023 and have a number of resources to ensure behavioral health providers have all the information they need to begin caring for Harvard Pilgrim commercial members.

Supporting Medicaid patients with redetermination

Tufts Health Public Plans

We want to ensure that our Medicaid members are aware that they must take action to have their eligibility redetermined and renew their coverage — and you and your practice play an important role in assisting with these efforts.

Claims consultation events coming near you!

All products

After the resounding success of the July claims consultation event we hosted at our Canton, MA headquarters, Point32Health is delighted to share that we’re expanding the series beyond Massachusetts and offering events in other states.

ChoiceNet: no tiering changes for 2024

Harvard Pilgrim Health Care Commercial

For 2024, Point32Health will not be refreshing tier assignments for the Harvard Pilgrim’s ChoiceNet HMO and PPO plans; all provider tier classifications will remain consistent with classifications for the 2023 plan year.

Responding to requests for more information

All products

To avoid denials based on missing information needed for Point32Health to conduct a complete prior authorization review, and to avoid delays in patient care, please respond back timely to requests for more information.

Reminders and update: billing for PrEP and HIV services

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

When billing for HIV PrEP and other related services, please bill in accordance with our Harvard Pilgrim Patient Protection and Affordable Care Act (Federal Health Care Reform) policy and Tufts Health Plan Preventive Services Payment Policy.

MassHealth billing reminders

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

While MassHealth is working to renew member eligibility, there may be several eligibility updates occurring at this time. In MassHealth All Provider Bulletin 372, MassHealth shared important reminders of billing responsibilities and billing for retroactively reinstated members.

Promoting the flu vaccine

All products

The flu season runs from October through April each year, and given the ongoing COVID pandemic, it’s particularly important to emphasize the importance of getting the 2023-2024 flu vaccine to your patients. 

Reducing 30-day readmissions

All products

Reducing hospital readmissions within 30 days is a considerable priority in health care, leading to increased patient satisfaction and improved outcomes.

Metabolic monitoring for patients on antipsychotic medications

All products

Patients taking antipsychotic medications are at increased risk of developing health conditions including diabetes, high blood pressure, abnormal cholesterol and triglyceride levels, and obesity. Yearly screening and regular metabolic monitoring is vital for children, adolescents, and adults on these medications.

IET measure — tips to keep in mind

All products

As a follow-up to our July 2023 communication regarding the Initiation and Engagement of Substance Use Disorder Treatment (IET) HEDIS measure, which assesses the follow-up care patients receive after a new episode of substance use disorder (SUD), we’d like to offer some additional tips to keep in mind.

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.

Billing requirements updated for Spravato nasal spray

Harvard Pilgrim Health Care Commercial

Effective for dates of service beginning Nov. 1, 2023, Point32Health will require that providers billing for Spravato (esketamine) nasal spray for Harvard Pilgrim commercial members include HCPCS code G2082 or G2083 on the medical claim, in addition to HCPCS code S0013, which will also continue to be required.

Pharmacy coverage changes

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

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

Reminder: prior authorization for long-acting opioids

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

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.

New Stride payment policy

Harvard Pilgrim Stride (HMO) Medicare Advantage

We’ve developed a payment policy illustrating reimbursement, reporting, and billing policies and requirements for services related to serious reportable events and provider preventable conditions for our Harvard Pilgrim Health Care Stride (HMO)/(HMO-POS) Medicare Advantage products.

CMS billing update for home health services using telehealth

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

In keeping with a bulletin from the Centers for Medicare and Medicaid Services, Point32Health now requires providers to report one of the following remote patient monitoring codes, as applicable, when billing for home health services administered via telehealth to our Tufts Health Medicare Preferred or Tufts Health Plan Senior Care Options members.