Insights and Updates for Providers

September 2025

Update on medical record review programs

Tufts Health Direct | Tufts Health One Care | Tufts Health Plan Senior Care Options | Tufts Health RITogether | Tufts Health Together | Tufts Medicare Preferred

As you know, health plans conduct medical record review programs to ensure accurate billing, coding, and documentation practices and compliance with requirements.

Billing updates for mental health centers

Tufts Health One Care | Tufts Health Plan Senior Care Options | Tufts Health Together

Beginning Sept. 1, 2025, we will be reimbursing behavioral health urgent care centers for a core set of outpatient services using a bundled encounter rate per member per date of service.

New 2025 model of care training available

Tufts Health Plan Senior Care Options

Tufts Health Plan Senior Care Options (SCO) PCPs and specialists are reminded to complete the new 2025 SCO Model of training by the end of 2025.

Telehealth flexibilities for Medicare members

Tufts Health One Care | Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

Tufts Health Plan is extending some telehealth flexibilities for Medicare members and offering guidance on telehealth billing for these members.

Upcoming coverage changes for diabetic testing supplies

Tufts Health One Care | Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

Accu-Chek will become the preferred brand for blood glucose meters and test strips, and LifeScan’s One Touch test strips and meters will no longer be covered under the patient’s benefit.

Coverage changes for Stelara and biosimilars

Harvard Pilgrim Health Care Commercial | Tufts Health Direct | Tufts Health One Care | Tufts Health Plan Commercial | Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

There will be upcoming coverage changes related to Stelara and biosimilars, and we recommend prescribers write a new prescription to aid the transition.

Registration reminder for Electronic Visit Verification

Tufts Health One Care | Tufts Health Plan Senior Care Options | Tufts Health Together

Providers who haven’t completed their Electronic Visit Verification are encouraged to complete the process as soon as possible per the Massachusetts Executive Office of Health and Human Services.

Update on referral requirement for home health agency care

Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

Effective June 15, 2025 a provider/discharging facility order will satisfy the referral requirement for home health agency care for Tufts Medicare Preferred and Tufts Health Plan Senior Care Options.

Prior authorization for certain Part B drugs

Tufts Health Plan OneCare | Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

A recent temporary system error impacted the required authorization for a number of Medicare Part B drugs, and prior authorization should be submitted if not previously obtained.

Notice requirement for terminating practitioners

Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

Please notify Tufts Health Plan with at least 90 calendar days’ written notice prior to the effective date of a primary care provider or specialist terminating from our network.

Prior authorization reminder: intensity-modulated radiation therapy

Harvard Pilgrim Health Care Commercial | Tufts Health Direct | Tufts Health Plan Commercial | Tufts Health Plan Senior Care Options | Tufts Health RITogether | Tufts Health Together | Tufts Medicare Preferred

As a reminder, as of April 1 the previously announced continuity of care period has ended and a prior authorization must be obtained for all members starting IMRT prior to their course of treatment.

Skilled nursing care: prior authorization update

Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

We have amended a previous decision and prior authorization will not be required for skilled nursing care for Tufts Medicare Preferred members.

New medication adherence Star Measure tip sheet

Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

Point32Health has developed a new Star Measure tip sheet for the Medication Adherence measure for patients prescribed medication for diabetes, hypertension, or cholesterol.

Noncovered Investigational Services MNG for Senior Products

Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

Our newly developed MNG, effective April 1, 2025, details Noncovered Investigational Services for Tufts Medicare Preferred and Tufts Health Plan Senior Care Options (SCO).

Initial inpatient admission notification requirement update

Tufts Health One Care | Tufts Health Plan Senior Care Options | Tufts Health RITogether | Tufts Health Together | Tufts Medicare Preferred

As of April 1, Point32Health must be notified within one business day following a member’s admission to an inpatient facility.

Important authorization reminders for Senior Products

Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

Be sure to review these important reminders regarding new prior authorization requirements for Tufts Medicare Preferred and Tufts Health Plan Senior Care Options (SCO) members.

Continued stay and inpatient level of care reviews

Harvard Pilgrim Health Care Commercial | Senior Products | Tufts Health Direct | Tufts Health Plan Senior Care Options | Tufts Health RITogether | Tufts Health Senior Products | Tufts Health Together | Tufts Medicare Preferred

We’re sharing a reminder regarding continued stay reviews for DRG case rate admissions, and an update to our level of care review process for elective inpatient surgical procedures.

Add-on payments for corrective mobility system timely repairs

Tufts Health One Care | Tufts Health Plan Senior Care Options | Tufts Health Together

In support of guidance from MassHealth and the Executive Office of Health and Human Services, we will provide an additional add-on payment for corrective mobility system timely repairs.

Point32Health Medicare products: 2025 benefit changes

Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

We are providing updated benefit information for 2025 related to our Tufts Health Plan Senior Products, Tufts Medicare Preferred HMO/PPO and Tufts Health Plan Senior Care Options.

New prior authorizations for Senior Products in 2025

Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

We continually evaluate the prior authorization requirements we have in place to promote medical necessity and clinical appropriateness, and are instituting new requirements for a number of services.

What’s ahead for our Medicare plans for 2025

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

We are highlighting some updates to our Medicare Advantage plans for 2025, in connection with industrywide changes stemming from the IRA.

2025 Part B Step Therapy program

Tufts Health One Care | Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

Updates to the Part B Step Therapy program for Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, and Tufts Health One Care take effect Jan. 1.