Updates to medical drug claims editing logic
We’re updating medical drug claims editing logic to remove certain edits.
Insights and Updates for Providers
April 2024
Utilization management update for home health care services
We’re updating home health care UM requirements for quality and efficiency.
MNG update: Non-Emergency Medical Transportation
Integrated Point32Health Medical Necessity Guidelines for Non-Emergency Medical Transportation.
Standard form for Applied Behavior Analysis prior authorization requests
A standard authorization form for ABA services has been adopted.
Complex Care Management services
Point32Health provides complex care management services individually tailored to patients.
About Our Chronic Condition Management programs
Point32Health’s chronic condition management programs reinforce clinician treatment plans.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Reminder: trastuzumab biosimilar strategy
Reminder of our biosimilar strategy for trastuzumab oncology drugs.
Oral formula authorization request update
Clarification on how to request authorization for oral formula.
Reminder: Step therapy protocols and exceptions
Massachusetts law now requires mandatory exceptions in step therapy protocols.
Coverage update for mental health wellness examinations
Annual mental health wellness exams covered at no cost for certain members.
Billing for lead screening
Lead screenings for ages 0-6 years covered with no member cost share.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Expanded access to CGP for advanced solid tumors
We’re reminding providers of our comprehensive genomic profiling coverage and authorization process.
Harvard Pilgrim commercial fee schedule in effect April 1
Reminder: Harvard Pilgrim’s updated commercial fee schedule takes effect April 1.
Oral formula authorization request update
Change coming to the way oral formula is requested on authorizations.
Use code A4287 for coverage of breast milk storage bags
Use code A4287, not K1005, for coverage of breast milk storage bags.
Clarification: Prior authorization on insulin infusion pumps
Authorization required for insulin pumps which work in conjunction with a CGM device.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
2024 Physician Group Honor Roll announced
53 physician groups named to Harvard Pilgrim’s Physician Group Honor Roll.
Behavioral Health hub for members
New resource for Harvard Pilgrim members regarding behavioral health topics.
Important tips to minimize denials
Tips for a smooth Harvard Pilgrim commercial migration process and accurate claims reimbursement.
Ovia Health’s Family & Maternal Health Solutions
Ovia Health now available to Tufts Health Together and Tufts Health RITogether members.
Maine mandate and new coverage for donor breast milk
Beginning Jan. 1, donor breast milk will be covered for eligible infants in Maine.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Connecticut market exit reminder
Reminder about Harvard Pilgrim Health Care’s withdrawal of fully insured commercial products in Connecticut as of Jan. 1, 2024.
Crisis resource reminder for Massachusetts members
Learn more about Community Behavioral Health Center resources available in Massachusetts.
Maine mandates and new coverage
Commercial medical necessity guideline updates to align with recent legislation in Maine.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Reminder and clarification of billing requirements for Spravato
Reminder and clarification on billing for Spravato nasal spray.
Urine Drug Testing Payment Policy integration
Urine Drug Testing coverage and payment policy updates.
Updates on Rhode Island for 2024
Read about our 2024 commercial migration, new product, and more!
New ICD-10 code for HIV PrEP
HIV PrEP billing requirements and new ICD-10 code.
Pharmacy coverage changes
Jan. 1, 2024 Pharmacy coverage changes for various Point32Health products.
Preferred oncology biosimilars for 2024
Preferred products for the bevacizumab, rituximab, and trastuzumab drug classes.
Other 2024 Pharmacy program updates
2024 Pharmacy updates: Harvard Pilgrim commercial, Tufts commercial, Tufts Health Direct.
Point32Health PPACA coverage alignment
Jan. 1 coding/coverage updates to Harvard Pilgrim PPACA policy.
Complex Care Management services
Point32Health provides care management services for adult and pediatric members.
About Our Chronic Condition Management Programs
Point32Health’s approach to chronic condition management through patient-centered care.
Preparing for Behavioral Health Insourcing
Please refer to these tools and resources related to our behavioral health program, which insources on Nov. 1, 2023.
Inform Point32Health if you offer concierge medicine services
Providers who are planning to offer concierge medicine services to eligible members are required to provide advance notice.
Synagis coverage for the 2023-2024 RSV season
Point32Health would like to remind providers of our Synagis (palivizumab) policy for the 2023-2024 season.
Important behavioral health insourcing information
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.
ChoiceNet: no tiering changes for 2024
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.
Reminders and update: billing for PrEP and HIV services
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.
Billing requirements updated for Spravato nasal spray
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
Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.
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.
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.
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.