Insights and Updates for Providers

December 2023

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.

Behavioral Health Medical Necessity Guideline updates

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

We’re updating our Medical Necessity Guidelines for the behavioral health services Transcranial Magnetic Stimulation, Psychological Testing and Assessment, and Neuropsychological Testing and Assessment, effective for dates of service beginning July 1, 2023.

Behavioral Health Payment Policy update

Tufts Health Plan Commercial

Our new Behavioral Health and Substance Use Disorder Payment Policy, effective July 1, 2023 for Tufts Health Plan commercial members, details reimbursement for medically necessary services rendered in inpatient, outpatient and acute residential settings and includes billing guidelines.

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.

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.

Coverage updates for breastfeeding equipment and supplies

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

As of Jan. 1, 2023, Point32Health provides coverage for breastfeeding supplies including storage bags for breast milk (HCPCS code K1005) for certain products, with a quantity limit of 300 bags per three-month reimbursement period.

Expanded coverage of Community Behavioral Health Centers

Tufts Health Plan Commercial

Tufts Health Plan commercial members have access to two programs provided by Community Behavioral Health Centers (CBHCs) — Mobile Crisis Intervention (MCI) and Community Crisis Stabilization (CCS) — aimed at increasing access to care and promote community-based treatment options rather than emergency department visits for behavioral crisis intervention.

FDA-unapproved product coverage update

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

Effective immediately, any products listed on the Harvard Pilgrim Health Care commercial, Tufts Health Plan commercial, and Tufts Health Direct formularies that have not been approved by the FDA will be excluded from coverage, in alignment with the information listed on our Evidence of Coverage documents and Member Handbooks.

Generic inhalers coverage update

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

Effective Oct. 1, 2023, the identified generic inhaler products will not be covered in the formularies for Harvard Pilgrim Health Care commercial, Tufts Health Plan commercial and Tufts Health Direct. Alternative NDCs for the same drug, and similar agents, are covered on our formularies.

Home infusion claims update

Tufts Health Plan Commercial | Tufts Health Plan SCO | Tufts Medicare Preferred

Effective for dates of service beginning April 1, 2023, Tufts Health Plan is insourcing claims pricing and processing for home infusion services for Tufts Health Plan Commercial, Tufts Medicare Preferred and Tufts Health Plan Senior Care Options.

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.

Migration to 2023 InterQual criteria

Harvard Pilgrim Health Care Commercial | Tufts Health Plan Commercial | Tufts Health Public Plans

Point32Health utilizes InterQual criteria for clinical authorization review for a number of services. For the Medical Necessity Guidelines listed here, we will be adopting 2023 InterQual SmartSheets to replace the previous versions currently in use.

New ICD-10 code for HIV PrEP

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

HIV PrEP billing requirements and new ICD-10 code.

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.

NIA vendor program code updates

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

This chart identifies code updates to Point32Health and National Imaging Associates, Inc.’s (NIA’s) medical necessity review program, which are effective June 1, 2023 and intended to align coverage and criteria for the Harvard Pilgrim and Tufts Health Plan products included in the program.