Insights and Updates for Providers

June 2024

Care management Medicare role change

Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Medicare Preferred

Point32Health is making adjustments to certain care management functions to better coordinate on transitions of care for our members.

New Massachusetts Behavioral Health Resource Directory

Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Medicare Preferred

The Massachusetts BHHL has launched a resource directory — behavioral health providers are encouraged to confirm their practice is listed.

Pilot program offers in-home urgent care

Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

Select Senior Products members can opt into our in-home urgent care program, instED.

Complex Care Management services

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

Point32Health provides complex care management services individually tailored to patients.

About Our Chronic Condition Management programs

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

Point32Health’s chronic condition management programs reinforce clinician treatment plans.

Billing for COVID-19

Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Health One Care | Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

Modifier CS should no longer be used and claims with it may deny.

Coverage for services provided by LMFTs/LMHCs

Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Health One Care | Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

Effective Jan. 1, 2024, LMFTs and LMHCs will be recognized as Medicare-eligible providers.

Reminder: QMB Members Exempt from Part A/B Cost-Sharing

Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

Reminders for providers regarding Qualified Medicare Beneficiary enrollee exemption from cost-sharing liability.

Complex Care Management services

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

Point32Health provides care management services for adult and pediatric members.

About Our Chronic Condition Management Programs

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

Point32Health’s approach to chronic condition management through patient-centered care.

Inform Point32Health if you offer concierge medicine services

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

Providers who are planning to offer concierge medicine services to eligible members are required to provide advance notice.

2024 Part B Step Therapy program

Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Health Plan Senior Care Options | Tufts Health Unify | Tufts Medicare Preferred

New requirements will apply to the 2024 Part B Step Therapy program.

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.

Billing Medicare members for non-covered services 

Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Health Plan Senior Products

We would like to provide some reminders regarding the steps a contracted provider must take prior to billing members of our Harvard Pilgrim Health Care and Tufts Health Plan Medicare Advantage plans/Senior Products for non-covered services.

OncoHealth program update

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

In a continued effort to reduce prior authorization burden on providers and members, effective Sept. 1, 2023 these drugs will no longer require prior authorization through OncoHealth for oncology indications for members of Harvard Pilgrim’s commercial and Stride Medicare Advantage plans.

Update to Integra’s DMEPOS network: Senior Products

Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

Integra will soon begin to assume management of the DMEPOS provider network for Point32Health’s Senior Products, starting on July 1, 2023 for Tufts Medicare Preferred and Tufts Health Plan Senior Care Options, and on Sept. 1, 2023 for Harvard Pilgrim Stride (HMO)(HMO-POS) Medicare Advantage.

NIA vendor program code updates

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

In the April issue of Insights and Updates for Providers, Point32Health announced a number of changes expected to take effect June 1, 2023 in relation to the medical necessity review and prior authorization program that National Imaging Associates, Inc. (NIA) oversees on our behalf for certain procedures.