Point32Health would like to make providers who serve Harvard Pilgrim Health Care members aware that as of April 1, 2023, Harvard Pilgrim’s Commercial and StrideSM (HMO)/(HMO-POS) Medicare Advantage plans will no longer use OncoHealth for radiation oncology medical management.
While OncoHealth will continue to be Harvard Pilgrim’s vendor partner for medical review of chemotherapeutic protocols (chemotherapy, support and symptom management drugs), the prior authorization process for radiation therapy is changing.
For Harvard Pilgrim Commercial plans
Some codes will no longer require prior authorization, others will newly require it, and some codes will continue to require prior authorization — but this review will be conducted in-house by Point32Health in accordance with the standard Harvard Pilgrim prior authorization process instead of by OncoHealth. You can find more detailed information about these Commercial coding changes below.
Prior authorization will continue to be required for the following codes related to proton beam therapy (PBT), stereotactic radiosurgery (SRS), and stereotactic body radiotherapy (SBRT), but authorization review will be managed internally by Point32Health:
The following SRS/SBRT codes will newly require prior authorization for Harvard Pilgrim Commercial members to align with the existing Tufts Health Plan coverage:
The codes identified below (for various services) will continue to be covered for Harvard Pilgrim Commercial members and will no longer require prior authorization through OncoHealth or through Point32Health, which aligns with the current Tufts Health Plan coverage:
For the intensity-modulated radiation therapy codes 77385, 77386, G6015, and G6016, prior authorization will no longer be required for coverage for Harvard Pilgrim Commercial members. A new coverage guideline is being developed in relation to these services for all Point32Health lines of business, and will be available in advance of the April 1, 2023, effective date.
For Tufts Health Plan Commercial and Public Plans members
For Tufts Health Plan members, providers should continue to request prior authorization for radiation oncology services as they do today.
However, in alignment with Harvard Pilgrim’s current coverage, codes 61800, 61799, and 32701 will no longer require prior authorization for Tufts Health Plan Commercial and Tufts Health Public Plans members.
For Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage members
For Stride plans, prior authorization will no longer be required for any covered codes related to radiation therapy treatment plans for members with a cancer diagnosis who require such care.
Director, Provider Relations & Communications
Senior Manager, Provider Communications
Joseph O’Riordan, Jesse Salvato, Stephen Wong