Insights and Updates for Providers

July 2025

ChoiceNet and Focus Network – MA 2025

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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

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We’re introducing a streamlined Point32Health Drugs and Biologicals Payment Policy and will require providers to append modifier JW or JZ, when applicable.

Harvard Pilgrim Provider Portal required fields update

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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

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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

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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

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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

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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

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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

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We recently launched our behavioral health service navigation program to provide personalized guidance for patients seeking information regarding telebehavioral health care.

Pharmacy coverage changes

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

We have made updates to our pharmacy program; please refer to the Pharmacy Medical Necessity Guidelines page on our website for more details.