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
Reminder: Expansion of vendor program and training sessions
Beginning Oct. 1, 2025, Evolent will be conducting utilization management for spine and interventional pain management services for Tufts Medicare Preferred members.
Telehealth flexibilities for Medicare members
Tufts Health Plan is extending some telehealth flexibilities for Medicare members and offering guidance on telehealth billing for these members.
Expansion of vendor program for spine and interventional pain management services
Point32Health is expanding its Evolent program to include utilization management for spine and interventional pain management services for Tufts Medicare Preferred members.
Upcoming coverage changes for diabetic testing supplies
Accu-Chek will become the preferred brand for blood glucose meters and test strips, and LifeScan’s One Touch test strips and meters will no longer be covered under the patient’s benefit.
Coverage changes for Stelara and biosimilars
There will be upcoming coverage changes related to Stelara and biosimilars, and we recommend prescribers write a new prescription to aid the transition.
Reminder: Annual wellness visit covered by calendar year
Tufts Health Plan uses a calendar year for coverage of annual wellness visits for members of our senior products.
Update on referral requirement for home health agency care
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
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
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
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
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
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
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
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
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
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.
New pilot program offers virtual cardiac rehabilitation
Tufts Medicare Preferred members in Massachusetts can now choose to participate in a pilot program offered in collaboration with Movn Health, which provides telehealth cardiac rehabilitation following a heart event.
Submit corrected claims electronically for timely processing
We encourage our provider network to submit corrected claims electronically for Senior Products members for expedited claims processing.
Point32Health Medicare products: 2025 benefit changes
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.
Removing certain drugs from white bagging program
Effective for dates of service beginning Jan. 1, 2025, certain medications will be removed from the Office-Administered Medical Drugs list.
New prior authorizations for Senior Products in 2025
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.
Non-emergent medical transportation (ambulance) updates
Point32Health is making updates to our prior authorization requirements for non-emergent medical transportation effective Jan. 1, 2025 for Tufts Medicare Preferred only.
What’s ahead for our Medicare plans for 2025
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
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.
Claims editing platform updates
Updates to our claims editing platforms originally anticipated for Oct. 1, 2024 have been delayed and are now be expected to begin Jan. 1, 2025.