Utilization management update for home health care services
We’re updating home health care UM requirements for quality and efficiency.
Insights and Updates for Providers
April 2024
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.
Provider data, enrollment, and credentialing email address
We’re consolidating email addresses for submission of information to Tufts Health Plan.
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.
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.
Use code A4287 for coverage of breast milk storage bags
Use code A4287, not K1005, for coverage of breast milk storage bags.
Point32Health non-emergent ambulance reimbursement
Integrated Point32Health Ambulance and Transportation Services Payment Policy and reimbursement update.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Reminder: Psychological testing and TMS
Attach Psychological and Neuropsychological Assessment and/or rTMS form(s) to prior authorization requests.
Pharmacy program reminders
Point32Health would like to offer some reminders pertaining to our Pharmacy program.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Crisis resource reminder for Massachusetts members
Learn more about Community Behavioral Health Center resources available in Massachusetts.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Pharmacy program reminders
Coverage reminders related to our Pharmacy program.
Urine Drug Testing Payment Policy integration
Urine Drug Testing coverage and payment policy updates.
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.
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.
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.
Step Therapy Protocols and Exceptions
Learn more about mandatory exceptions in step therapy protocols.
Synagis coverage for the 2023-2024 RSV season
Point32Health would like to remind providers of our Synagis (palivizumab) policy for the 2023-2024 season.
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.
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.
Expanded coverage of Community Behavioral Health Centers
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.
Reminder: P.O. Box changes for referral forms
Tufts Health Plan encourages electronic submission of referrals for greater convenience and a real-time receipt of a referral number. Alternatively, providers may submit outpatient referrals using paper referral forms to the updated mailing addresses identified in this article.
Migration to 2023 InterQual criteria
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.
Pharmacy coverage changes
Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.
Prenatal vitamin coverage update
Effective for fill dates on or after Jan. 1, 2024, Harvard Pilgrim Health Care Commercial Plans, Tufts Health Plan Commercial Plans and Tufts Health Plan Direct will only cover prescription generic prenatal vitamins on our pharmacy formulary.
Generic inhalers coverage update
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.
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.
FDA-unapproved product coverage update
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.
Pharmacy coverage changes
Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.
Behavioral Health Payment Policy update
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.
NIA vendor program code updates
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.
Point32Health Medical Necessity Guideline updates
Review this chart for information on updates to Medical Necessity Guidelines (MNGs) associated with Point32Health’s products
Providers and office staff can refer to the following chart to review information on changes and updates to Medical Necessity Guidelines (MNGs) pertaining to the various products under the Point32Health umbrella.
Pharmacy coverage changes
Review this chart for updated Pharmacy Medical Necessity Guidelines with changes effective August 1, 2023 for Point32Health’s Pharmacy drug prior authorization program.
Removing certain drugs from white-bagging program
Effective for dates of service beginning July 1, 2023, the medications identified in this article will no longer be offered through CVS Caremark as part of Tufts Health Plan’s office-administered medical drug/white bagging program.
Reimbursement update for IEP services effective July 1
Effective for dates of service beginning July 1, 2023, Point32Health will no longer provide reimbursement for claims submitted with modifiers TM and TR for services provided in conjunction with a student’s individualized education program.
Behavioral Health Medical Necessity Guideline updates
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.