As you’re aware, Point32Health utilizes claims edits to support correct coding and we’re continually evaluating edits for consistency. As a result, for greater alignment across products, effective for dates of service beginning Nov. 1, 2024 we will apply certain edits for our Harvard Pilgrim Health Care Commercial plans that are currently in place for Tufts Health Plan Commercial, Tufts Health Public Plans, and Tufts Health Plan Senior Products (Tufts Medicare Preferred and Tufts Health Plan Senior Care Options).
The edits will utilize coverage criteria from Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), where applicable. Examples of applicable NCDs and LCDs include, but are not limited to:
- Transthoracic Echocardiography
- Duplex Scanning
- Peripheral Venous Ultrasound
- Non-invasive Extracranial Arterial Studies
- Cardiac Catheterization and Coronary Angiography
Refer to Point32Health’s General Coding and Claims Editing Payment Policy for guidance on correct coding and general industry standards.