2025 Physician Group Honor Roll announced
We would like to congratulate the 56 physician groups in Harvard Pilgrim’s Commercial network named to our 23rd annual Physician Group Honor Roll.
Insights and Updates for Providers
January 2025
Insourcing chronic kidney disease care management
Point32Health will be insourcing chronic kidney disease (CKD) care management services for Harvard Pilgrim Health Care and Tufts Health Plan Commercial members beginning Jan. 1, 2025.
About our products with the Painters and Iron Workers Unions
Harvard Pilgrim is pleased to offer shared administration plans for the Painters & Allied Trades District Council No. 35 and the Iron Workers District Council of New England/Iron Clad unions.
Use our secure HPHConnect portal for speedy self-service
We encourage providers and office staff to use our secure HPHConnect portal to conduct a variety of self-service transactions for Harvard Pilgrim Health Care Commercial members.
Continued stay and inpatient level of care reviews
We’re sharing a reminder regarding continued stay reviews for DRG case rate admissions, and an update to our level of care review process for elective inpatient surgical procedures.
PPACA coverage policy updates for 2025
We’ve made minor updates to the Harvard Pilgrim Patient Protection and Affordable Care Act Policy, and we’ve developed equivalent policies for Tufts Health Plan Commercial and Direct.
Coverage for inpatient donor human milk
As of Nov. 21, 2024, Point32Health will now cover medically necessary inpatient donor human milk and donor human milk-derived products for members of certain Massachusetts plans.
Pharmacy coverage changes
We have made updates to our pharmacy program; please refer to the Pharmacy Medical Necessity Guidelines page on our website for more details.
Portal, phone, and fax update for referrals, notifications and authorizations
In recent issues, we announced some updates on reaching us by phone, email, and fax, and are providing the following clarifications and reminders.
Reminder: Update on our behavioral health network
With our robust, insourced behavioral health network now firmly established, effective Jan. 1, 2025, non-contracted Harvard Pilgrim providers will no longer be considered in network.
Claims denial process update for Maine
Consistent with new Maine regulation, we will no longer deny claims from network providers for failure to obtain prior authorization.
Orphan Drug Program launch
Point32Health is collaborating with OptumRx, our pharmacy benefit manager, to introduce a new Orphan Drug Program, available Jan. 1, 2025.
Billing for behavioral health boarding
We’ve clarified the billing requirements outlined in our payment policies pertaining to BH boarding, and have updated a BH boarding billing requirement for Tufts Health Direct.
Observation Stay Payment Policy and process change
Effective Jan. 1, 2025, Point32Health is making a change to our review process for short inpatient stays and observation services.
Update on our behavioral health network
With our robust, insourced behavioral health network now firmly established, effective Jan. 1, 2025, non-contracted Harvard Pilgrim providers will no longer be considered in network.
Pharmacy coverage changes
The following changes to Point32Health’s Pharmacy program take effect on Jan. 1, 2025, including prior authorization, drug status, and formulary updates for various products.
Removing certain drugs from white bagging program
Effective for dates of service beginning Jan. 1, 2025, certain medications will be removed from the Office-Administered Medical Drugs list.
Other 2025 Pharmacy program updates
We are providing pharmacy updates for the 2025 plan year regarding formularies, weight loss prescription drugs and diabetic GLP-1 coverage, and adalimumab.
2025 medical benefit step therapy program
The chart in this article outlines a new medical benefit step therapy program, which will be effective for fill dates on or after Jan. 1, 2025.
Expansion of cryopreservation and storage coverage
Our cryopreservation and storage benefit now includes coverage for ovarian tissue and testicular tissue, in addition to the previous coverage for sperm, eggs, and embryos.
New ICD-10 codes available for diabetic shoes
Effective Nov. 1, 2024, Harvard Pilgrim Health Care Commercial members can use newly released ICD-10 codes for diabetic shoes.
New Point32Health webpages to streamline your operations
We are announcing a few integrated webpages to streamline the provider experience, including our Prior Authorization, Forms, and Vendor Programs pages.
Submitting behavioral health claims and appeals
Beginning Nov. 1, submit all BH claims and appeals directly to Harvard Pilgrim for Commercial members — even for dates of service prior to Nov. 1, 2023.
Updated address for Harvard Pilgrim mail correspondence
We are updating the address for our Harvard Pilgrim Health Care line of business from Quincy to our corporate address in Canton.
New product offering for Jan. 1, 2025
Point32Health will offer a new Harvard Pilgrim Health Care Commercial product, PPO Access, beginning Jan. 1, 2025.
Billing for NH community-based mental health organizations
Providers treating children with severe mental illness through one of New Hampshire’s 10 Community Mental Health Centers may be able to bill for certain services.
Synagis coverage for the 2024-2025 RSV season
We would like to remind providers that Synagis requires prior authorization, and how to request authorization for the 2024-2025 season.
ChoiceNet and Focus Network – MA 2025
Tier assignments for Harvard Pilgrim’s ChoiceNet HMO and PPO plans, determined based on quality and cost performance, take effect January 1, 2025.
Payment Policy update and modifier requirements
We’re introducing a streamlined Point32Health Drugs and Biologicals Payment Policy and will require providers to append modifier JW or JZ, when applicable.
Claims edits for Harvard Pilgrim Commercial plans
Effective Nov. 1, 2024 we will apply certain edits for our Harvard Pilgrim Commercial plans that are currently in place for Tufts Health Plan.
Harvard Pilgrim Provider Portal required fields update
Harvard Pilgrim is making an update to the electronic prior authorization request submission in HPHConnect when submitting an outpatient service transaction, effective Nov. 1, 2024.
Coverage update for mental health wellness examinations
Mental health wellness examinations will now be covered annually at no cost to Tufts Health Together members, effective retroactively beginning July 1, 2024.
Psychotherapy services billing reminder
When billing for psychotherapy services, use the procedure code that most closely reflects the duration of time spent with the patient during the session.
Pharmacy coverage changes
We have made updates to our pharmacy program; please refer to the Pharmacy Medical Necessity Guidelines page on our website for more details.
Reminder on home infusion administration
Authorization is not required for the administration of home infusion drugs; however, it is still required for the home infusion drugs themselves.
Prior authorization required for noninvasive prenatal testing
Point32Health requires prior authorization for coverage of all prenatal testing, including NIPT, which can be requested using the resources provided here.
Behavioral health service navigation program for members
We recently launched our behavioral health service navigation program to provide personalized guidance for patients seeking information regarding telebehavioral health care.
Pharmacy coverage changes
We have made updates to our pharmacy program; please refer to the Pharmacy Medical Necessity Guidelines page on our website for more details.
Change Healthcare update: Timely filing limits and claim adjustment requirements to resume
Point32Health will return to our standard requirements for all lines of business regarding timely filing and claim adjustments, effective Sept. 1, 2024.
Recovering negative balances
We have outlined reasons why a claim may be retracted, resulting in a negative balance, and ways to resolve a negative balance.
ConnectorCare plans – in-network coverage reminder
Harvard Pilgrim has joined Tufts Health Plan as a ConnectorCare issuer for 2024, expanding access to affordable health care coverage for thousands of Massachusetts residents.
Reminder: removal of certain prior authorization requirements
We would like to remind our providers of certain procedures and associated codes that no longer require prior authorization.
Coverage reminder – Community Behavioral Health Center services
We would like to remind providers of notification requirements and billing procedures related to Community Behavioral Health Center services.
Pharmacy coverage changes
We have made updates to our pharmacy program; please refer to the Pharmacy Medical Necessity Guidelines page on our website for more details.
Removal of prior authorization requirements for certain procedures
We are removing prior authorization requirements from certain procedures and associated codes in a continued effort to administratively simplify providers’ experience.
2024 Home Care Seasonal Flu Vaccine Fee Schedule
Updates to Harvard Pilgrim’s standard home care seasonal influenza vaccine fee schedule will take effect on Aug. 1, 2024
Good Measures Healthy Weight program launches for members
Harvard Pilgrim Health Care has partnered with Good Measures to offer their Healthy Weight program to members with certain weight/nutrition-related conditions.
Pharmacy coverage changes
Read about updates to Point32Health’s Pharmacy program and our Pharmacy Medical Necessity Guidelines for Harvard Pilgrim and Tufts Health Plan.
Telehealth reimbursement update for BH services
Increased reimburse rate for BH telehealth services provided by non-BH providers.
Reminder: Value codes required on ESRD claims
Required value codes when billing for end-stage renal disease services.