Insights and Updates for Providers

March 2024

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 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 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.

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.

Step Therapy Protocols and Exceptions

Harvard Pilgrim and Tufts Commercial | Tufts Health Direct | Tufts Health Plan Commercial | Tufts Health Plan SCO-Medicaid Only Plans | Tufts Health Together

Learn more about mandatory exceptions in step therapy protocols.

MassHealth billing reminders

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

While MassHealth is working to renew member eligibility, there may be several eligibility updates occurring at this time. In MassHealth All Provider Bulletin 372, MassHealth shared important reminders of billing responsibilities and billing for retroactively reinstated members.

Billing for specialized Community Support Program services

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

This article provides an overview of MassHealth’s Community Support Program (CSP) Services, available to members of the Tufts Health Plan Together, Tufts Health Unify, and Tufts Health Plan Senior Care Options products, as well as information about billing and notification requirements.

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.

MassHealth Unified Formulary updates

Tufts Health Together

We’re sharing some updates regarding medical benefit drug coverage and the MassHealth Unified Formulary, which will apply for Tufts Health Together beginning July 31, 2023.

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.

Reminder of telehealth billing requirements

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

We’re offering some reminders and clarifying information on billing for telehealth services for Tufts Health Plan Senior Care Options, Tufts Health Together, and Tufts Health Unify members.

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.

MassHealth Unified Formulary: medical drug updates

Tufts Health Together

Tufts Health Together–MassHealth MCO Plan and ACPPs now utilize MassHealth’s Unified Formulary for pharmacy medications and for select medical benefit drugs. Effective June 5, 2023, these updates regarding medical drugs and the MassHealth Unified Formulary will apply,

Pharmacy coverage changes

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

Review this chart for updated Pharmacy Medical Necessity Guidelines with changes effective August 1, 2023 for Point32Health’s Pharmacy drug prior authorization program.

Reimbursement update for IEP services effective July 1

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

Effective for dates of service beginning July 1, 2023, Point32Health will no longer provide reimbursement for claims submitted with modifiers TM and TR for services provided in conjunction with a student’s individualized education program.

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.

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.

Submitting newborn claims appropriately

Tufts Health Together | Tufts Health Unify

As a reminder, MassHealth All Provider Bulletin 305 explains billing practices for newborn children of all MassHealth members and applies to Tufts Health Together and Unify plans. These guidelines require that providers bill for newborn services separately and not under the mother’s member ID number.

Behavioral health performance specifications updated

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

As part of our ongoing review of performance specifications, we revised the behavioral health performance specifications identified in this article, applicable to certain Tufts Health Plan products, effective April 1, 2023.

Opioid Policy Update

Tufts Health Together

While Tufts Health Together will be adopting MassHealth’s Unified Formulary on April 1 for Tufts Health Together, we will follow different thresholds for opioid dosage and will be implementing a number of opioid clinical programs as part of the Unified Formulary.

Billing for telehealth

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

Tufts Health Plan is making some updates to our payment policies related to the submission of professional claims for services provided via telehealth, and also reprocessing certain previously denied claims to be reimbursed, in accordance with MassHealth’s MCE Bulletin 95.

Reminder: MassHealth Unified Formulary

Tufts Health Together

Effective April 1, 2023, Tufts Health Together–MassHealth MCO Plan and ACPPs, in conjunction with the other Medicaid managed care organizations (MCOs) in the Commonwealth, will be utilizing MassHealth’s Unified Formulary for pharmacy medications and for select medical benefit drugs.

MassHealth unified formulary eff. 4/1

Tufts Health Together

Effective April 1, 2023, Tufts Health Together–MassHealth MCO Plan and ACPPs will be utilizing MassHealth’s Unified Formulary for pharmacy medications and for select medical benefit drugs, and pharmacy coverage and criteria for Tufts Health Together consequently will mirror that of MassHealth.

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.

Acute behavioral health services for Tufts Health Plan

Tufts Health Direct | Tufts Health Plan MA Commercial products | Tufts Health Plan SCO | Tufts Health Together | Tufts Health Unify

Tufts Health Plan has updated the notification requirement for acute behavioral health services updated from two to three business days for Tufts Health Plan Massachusetts Commercial products, Tufts Health Together, Tufts Health Unify and Tufts Health SCO.