Point32Health maintains an Individual Consideration Services Payment Policy, which outlines billing and compensation for certain services which are denoted in the MassHealth Physician Manual as “individual consideration” — i.e., services for which MassHealth does not have an established compensation rate, or services which may not have an established rate for any other reason.
Point32Health covers medically necessary services in accordance with the member’s benefits and in accordance with provider contracts, when applicable.
The Individual Consideration Services Payment Policy is being updated to clarify its intent, and will apply to Tufts Health Direct (in addition to Tufts Health Together) claims for any service designated as “individual consideration” or without an established fee for any reason. Beginning June 1, 2024, for any covered service, any procedure code designated as being an “individual consideration” procedure code or any service for which a fee has not been established will be reimbursed based according to Medicare’s reimbursement methodology and the Tufts Health Plan fee schedules. When a rate does not exist, the service will be reimbursed at 35% of billed charges.
For more information, please refer to Point32Health’s updated Individual Consideration Services Payment Policy.