Insights and Updates for Providers

July 2025

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.

Pharmacy coverage changes

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

Refer to the following chart for information regarding upcoming pharmacy coverage changes.

Updates to observation stay authorizations

Tufts Health One Care | Tufts Health RITogether | Tufts Health Together

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

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

Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.

Carelon molecular diagnostic testing program update

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

Our vendor partner for molecular diagnostic testing, Carelon, is implementing an update effective Aug. 1, 2025 regarding defining its service dates.

Pharmacy coverage changes

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

Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.

Claims editing platform updates

Harvard Pilgrim Health Care Commercial | Tufts Health Direct | Tufts Health Plan Senior Care Options (SCO) Medi | Tufts Health RITogether | Tufts Health Together

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

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.

Pharmacy coverage changes

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

Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.

Pharmacy coverage changes

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

Please refer to this chart for information on updates to our Pharmacy coverage and Medical Necessity Guidelines.

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.

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.

Billing for routine eye care services

Tufts Health Together

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

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

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

Tufts Health Direct | Tufts Health One Care | Tufts Health RITogether | Tufts Health Together

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

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

We have made updates to our pharmacy program; please refer to the Pharmacy Medical Necessity Guidelines page on our website for more details.

Pharmacy coverage changes

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

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

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

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.

Coverage update for mental health wellness examinations

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

Mental health wellness examinations will now be covered annually at no cost to Tufts Health Together members, effective retroactively beginning July 1, 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.