Insights and Updates for Providers

July 2025

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.

InstED in-home urgent care pilot expands availability

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

We are expanding our instED program to members in Bristol, Plymouth, Hampshire, and Hampden counties in MA, and Hillsborough and Rockingham counties in NH.

Payment Policy update and modifier requirements

Harvard Pilgrim Health Care Commercial | Tufts Health Plan Commercial | Tufts Health Plan Senior Care Options | Tufts Health Public Plans | Tufts Medicare Preferred

We’re introducing a streamlined Point32Health Drugs and Biologicals Payment Policy and will require providers to append modifier JW or JZ, when applicable.

New 2024 Model of Care Training available

Tufts Health Plan Senior Care Options

We encourage Tufts Health Plan SCO PCPs and specialists to complete the new 2024 SCO Model of Care training by December 31, 2024.

Capped rental modifiers: reminder and clarification

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

Capped rental durable medical equipment should be billed with the appropriate capped rental modifier, in accordance with correct coding practices, to ensure reimbursement.

Behavioral health service navigation program for members

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

We recently launched our behavioral health service navigation program to provide personalized guidance for patients seeking information regarding telebehavioral health care.