Insights and Updates for Providers

March 2023

Harvard Pilgrim Provider Portal required fields update

Harvard Pilgrim Health Care Commercial

Harvard Pilgrim is making an update to the electronic prior authorization request submission process in HPHConnect, effective May 4, 2023. As a result, Contact Name and Contact Info will become required fields when submitting an outpatient service transaction.

Requests for assisted reproductive technology services

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

We would like to provide some clarity regarding the correct processes for initiating prior authorization requests for assisted reproductive technology services for members of Harvard Pilgrim Health Care Commercial products, Tufts Health Plan Commercial products, and Tufts Health Direct.

Hydration therapy reimbursement update

Harvard Pilgrim Health Care Commercial

Effective for dates of service beginning May 1, 2023, Harvard Pilgrim Health Care’s Commercial plans will no longer provide reimbursement for hydration therapy (CPT codes 96360, 96361, J7030, J7040, J7042, J7050, J7060, J7070, J7120, or J7121) when billed without a requisite diagnosis on the claim for members older than 18 years of age.

Update: Preferred product strategy for oncology drugs

Harvard Pilgrim Health Care Commercial

Harvard Pilgrim Health Care and OncoHealth are implementing a step therapy/preferred product strategy for a number of drug classes, effective for dates of service beginning April 1, 2023 for Harvard Pilgrim Commercial members.

Change to OncoHealth radiation program on April 1

Harvard Pilgrim Health Care Commercial  |  Harvard Pilgrim Stride (HMO) Medicare Advantage  |  Tufts Health Plan Commercial  |  Tufts Health Public Plans

As of April 1, 2023, Harvard Pilgrim’s Commercial and Stride (HMO)/(HMO-POS) Medicare Advantage plans will no longer use OncoHealth for radiation oncology medical management.

Obtaining oral formulas

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

Beginning April 1, 2023 for Harvard Pilgrim members, oral enteral formulas must be obtained through a contracted durable medical equipment provider, rather than at a retail pharmacy in order for them to be covered.

AIM Specialty Health name changing

Harvard Pilgrim Health Care Commercial  |  Harvard Pilgrim Stride (HMO) Medicare Advantage  |  Tufts Health Public Plans

Beginning March 1, 2023, AIM Specialty Health (Harvard Pilgrim and Tufts Health Public Plans’ genetic/genomic and molecular diagnostic testing services utilization management vendor) will be known by a new name: Carelon Medical Benefits Management.