Update on medical record review programs
As you know, health plans conduct medical record review programs to ensure accurate billing, coding, and documentation practices and compliance with requirements.
Insights and Updates for Providers
September 2025
Billing updates for mental health centers
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 MassHealth resources for providers
We’re pleased to share some new resources related to prenatal and postpartum care from MassHealth for providers and members.
Updates to Targeted Case Management Services’ ICC Medical Necessity Guidelines
We’ve revised our Targeted Case Management Services: Intensive Care Coordination (ICC) Medical Necessity Guidelines to reflect the state’s updated guidance.
MassHealth updates to Unified Formulary
MassHealth recently announced updates to the MassHealth Unified Formulary, which will take effect on Oct. 1, 2025.
Pharmacy coverage changes
Refer to this chart for information regarding upcoming pharmacy coverage changes.
Registration reminder for Electronic Visit Verification
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.
MassHealth to introduce CBHI-FIT program
MassHealth’s Children’s Behavioral Health Initiative is introducing its new Family-based Intensive Treatment program in September.
Pharmacy coverage changes
Refer to the following chart for information regarding upcoming pharmacy coverage changes.
Updates to observation stay authorizations
Effective Aug. 1, 2025, we will no longer authorize observation stays longer than 48 hours for Tufts Health Together, Tufts Health RITogether, and Tufts Health One Care.
Pharmacy coverage changes
Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.
Carelon molecular diagnostic testing program update
Our vendor partner for molecular diagnostic testing, Carelon, is implementing an update effective Aug. 1, 2025 regarding defining its service dates.
Pharmacy coverage changes
Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.
MassHealth coverage change for rapid-acting insulin products
Prior authorization is now required for Tufts Health Together members prescribed insulin Aspart, to encourage the use of cost-effective short-acting insulin agents.
Submission deadline for outstanding 2024 MassHealth claims
We’re reminding providers of MassHealth’s submission deadline for outstanding claims, claims corrections, and claims appeals for services provided between Jan. 1, 2024 and Dec. 31, 2024.
Claims editing platform updates
In an effort to consistently apply industry standard claims edits reflecting national correct coding and guidelines from state regulatory agencies, we’re making updates to align our claims editing platforms.
Prior authorization reminder: intensity-modulated radiation therapy
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.
Pharmacy coverage changes
Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.
Pharmacy coverage changes
Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.
Initial inpatient admission notification requirement update
As of April 1, Point32Health must be notified within one business day following a member’s admission to an inpatient facility.
Continued stay and inpatient level of care reviews
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
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.
Billing for routine eye care services
As a reminder for optometrists and ophthalmologists who treat Tufts Health Together members, routine eye exams should be reported using CPT codes 92002, 92004, 92012, and 92014.
Coverage for inpatient donor human milk
As of Nov. 21, 2024, Point32Health will now cover medically necessary inpatient donor human milk and donor human milk-derived products for members of certain Massachusetts plans.
Prior authorization requirements for cardiac services
Effective for dates of service beginning March 1, 2025, Point32Health and Evolent are adding prior authorization requirements for a number of additional cardiac services.
Pharmacy coverage changes
We have made updates to our pharmacy program; please refer to the Pharmacy Medical Necessity Guidelines page on our website for more details.
New pilot program offers in-home health evaluations
Tufts Health Together is offering a pilot program to provide in-home and virtual health evaluations to patients, in collaboration with Signify Health.
Pharmacy coverage changes
The following changes to Point32Health’s Pharmacy program take effect on Jan. 1, 2025, including prior authorization, drug status, and formulary updates for various products.
2025 medical benefit step therapy program
The chart in this article outlines a new medical benefit step therapy program, which will be effective for fill dates on or after Jan. 1, 2025.