Insights and Updates for Providers

January 2025

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.

New pilot program offers virtual cardiac rehabilitation

Tufts Medicare Preferred

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.

Point32Health Medicare products: 2025 benefit changes

Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

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

Harvard Pilgrim Health Care Commercial | Tufts Health Direct | Tufts Health Plan Commercial | Tufts Medicare Preferred

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

Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

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.

What’s ahead for our Medicare plans for 2025

Harvard Pilgrim Health Care Stride (HMO)/(HMO-POS) Medicare Advantage | Tufts Health One Care | Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

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

Tufts Health One Care | Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

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

Tufts Medicare Preferred

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.

InstED in-home urgent care pilot expands availability

Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

We are expanding our instED program to members in Bristol, Plymouth, Hampshire, and Hampden counties in MA, and Hillsborough and Rockingham counties in NH.

Payment Policy update and modifier requirements

Harvard Pilgrim Health Care Commercial | Tufts Health Plan Commercial | Tufts Health Plan Senior Care Options | Tufts Health Public Plans | Tufts Medicare Preferred

We’re introducing a streamlined Point32Health Drugs and Biologicals Payment Policy and will require providers to append modifier JW or JZ, when applicable.

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.

Claims editing platform updates

Tufts Medicare Preferred

We’re making updates to our claims editing platforms, effective Oct. 1, 2024 for our Tufts Medicare Preferred members.

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.

Care management Medicare role change

Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Medicare Preferred

Point32Health is making adjustments to certain care management functions to better coordinate on transitions of care for our members.

New Massachusetts Behavioral Health Resource Directory

Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Medicare Preferred

The Massachusetts BHHL has launched a resource directory — behavioral health providers are encouraged to confirm their practice is listed.

Pilot program offers in-home urgent care

Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Health Plan Senior Care Options | Tufts Medicare Preferred

Select Senior Products members can opt into our in-home urgent care program, instED.

Complex Care Management services

Harvard Pilgrim Health Care Commercial | Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Health Plan Commercial | Tufts Health Public Plans | Tufts Medicare Preferred

Point32Health provides complex care management services individually tailored to patients.

About Our Chronic Condition Management programs

Harvard Pilgrim Health Care Commercial | Harvard Pilgrim Stride (HMO) Medicare Advantage | Tufts Health Plan Commercial | Tufts Medicare Preferred

Point32Health’s chronic condition management programs reinforce clinician treatment plans.

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.