Insights and Updates for Providers

March 2024

Pharmacy coverage changes

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

Pharmacy coverage changes for various Point32Health products.

Expanded access to CGP for advanced solid tumors

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

We’re reminding providers of our comprehensive genomic profiling coverage and authorization process.

Point32Health non-emergent ambulance reimbursement

Harvard Pilgrim and Tufts Commercial | Tufts Health Direct | Tufts Health One Care | Tufts Health Plan Commercial | Tufts Health Plan SCO | Tufts Health RITogether | Tufts Health Together | Tufts Medicare Preferred

Integrated Point32Health Ambulance and Transportation Services Payment Policy and reimbursement update.

Pharmacy coverage changes

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

Pharmacy coverage changes for various Point32Health products.

Pharmacy program reminders

Harvard Pilgrim and Tufts Commercial | Tufts Health Direct | Tufts Health Plan Commercial | Tufts Health RITogether | Tufts Health Together

Point32Health would like to offer some reminders pertaining to our Pharmacy program.

Pharmacy coverage changes

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

Pharmacy coverage changes for various Point32Health products.

Pharmacy coverage changes

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

Pharmacy coverage changes for various Point32Health products.

Pharmacy program reminders

Harvard Pilgrim and Tufts Commercial | Tufts Health Direct | Tufts Health Plan Commercial | Tufts Health RITogether | Tufts Health Together

Coverage reminders related to our Pharmacy program.

Pharmacy coverage changes

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

Jan. 1, 2024 Pharmacy coverage changes for various Point32Health products.

Preferred oncology biosimilars for 2024

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

Preferred products for the bevacizumab, rituximab, and trastuzumab drug classes.

Synagis coverage for the 2023-2024 RSV season

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

Point32Health would like to remind providers of our Synagis (palivizumab) policy for the 2023-2024 season.

Pharmacy coverage changes

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

Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.

Rhode Island professional fee schedule updates

Tufts Health RITogether

Beginning Oct. 1, 2023, Point32Health will be updating the Rhode Island Medicaid professional fee schedule we use to determine claims reimbursement for services rendered to Tufts Health RITogether members.  

Behavioral Health and substance use disorder tools and resources

Tufts Health RITogether

Tufts Health RITogether providers have access to several behavioral health and substance use disorder resources. You’ll find information on behavioral health coverage, prior authorization and notification for behavioral health services, resources such as our Provider Manual, and more on the Tufts Health RITogether behavioral health webpage.

Claims filing requirement for court-ordered service

Tufts Health RITogether

For RITogether members, Tufts Health Plan will not require prior authorization for claims for court-ordered mental health/substance abuse services, for dates of service beginning July 1, 2023. 

Pharmacy coverage changes

Harvard Pilgrim and Tufts Commercial | Tufts Health Direct | Tufts Health Plan Commercial | Tufts Health RITogether | Tufts Health Together

Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.

Pharmacy coverage changes

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

Read more for information on updates to Point32Health’s Pharmacy prior authorization programs.

Update for acute inpatient facility readmissions

Tufts Health Direct | Tufts Health RITogether | Tufts Health Together | Uncategorized

Please be aware that for dates of service beginning Sept. 1, 2023, the readmission policies for DRG facilities for Tufts Health Direct, Tufts Health Together, and Tufts Health RITogether will be expanded to apply to providers reimbursed at a case rate.

Standard annual eligibility review process returning

Tufts Health Plan SCO | Tufts Health RITogether | Tufts Health Together | Tufts Health Unify

Because the annual renewal process for Medicaid members has resumed, over the next year all Medicaid members will need to have their eligibility re-determined. Please remind your Medicaid patients to complete the renewal process.

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.

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.

Medicaid enrollment/screening deadline

Tufts Health Plan SCO | Tufts Health RITogether | Tufts Health Together | Tufts Health Unify

Federal regulations require that providers who serve Medicaid members — including those who participate in Tufts Health RITogether, Tufts Health Together – MassHealth MCO Plan and Accountable Care Partnership Plans, Tufts Health Senior Care Options, and Tufts Health Unify — are screened by and enrolled with the appropriate state Medicaid agency.

Enrollment/screening process for Medicaid providers

Tufts Health RITogether | Tufts Health Together | Tufts Health Unify

Federal regulations require that providers who render services for Medicaid members are screened by and enrolled with the appropriate state Medicaid agency. If you have not yet completed this enrollment/screening process for your applicable patients, please do so.

Pharmacy coverage changes

Harvard Pilgrim and Tufts Commercial | Tufts Health Direct | Tufts Health RITogether

Please refer to this chart to review updates to pharmacy prior authorization programs applicable to Harvard Pilgrim Health Care and Tufts Health Plan products.

Pediatric services rate increase

Tufts Health RITogether

In accordance with recent action by the Rhode Island Executive Office of Health and Human Services, Tufts Health Plan is issuing a rate increase retroactive for dates of service on or after July 1, 2022 for certain pediatric claims for Tufts Health RITogether.

Personal care services rate increase

Tufts Health RITogether

In alignment with a rate increase implemented by the Rhode Island Executive Office of Health and Human Services, Tufts Health Plan will automatically reprocess any claims submitted for personal care services between July 1, 2022 and Jan. 25, 2023.