Point32Health’s approach to chronic condition management through patient-centered care.
Insights and Updates for Providers
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.
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.
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.
Point32Health provides care management services for adult and pediatric members.
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.
Learn more about Community Behavioral Health Center resources available in Massachusetts.
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.
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.
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.
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.
Providers who are planning to offer concierge medicine services to eligible members are required to provide advance notice.
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.
HIV PrEP billing requirements and new ICD-10 code.
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.
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.