Please remember to visit our Integration FAQ for answers to common questions about the combination of Harvard Pilgrim Health Care and Tufts Health Plan under our parent organization, Point32Health.
Recently added information and reminders include:
- Confirm the member’s product — As we continue to move members from Tufts Health Plan Commercial plans to Harvard Pilgrim Health Care commercial plans, it’s important to check member eligibility. We encourage you to ask for the member’s ID card and to use our secure provider portals to check member eligibility and benefits. For Harvard Pilgrim, use HPHConnect; For Tufts Health Plan members, visit the Tufts Health Plan secure provider portal.
- Eligibility transactions (270/271s) — In an effort to minimize eligibility transaction rejections for migrating members and resubmissions, Point32Health is automatically returning eligibility information for migrating members with the correct Plan details. For example, if a request is sent to Tufts Health Plan for a member who recently migrated from Tufts Health Plan Commercial to Harvard Pilgrim Commercial, information returned will note the correct Harvard Pilgrim policy and benefit information. If you utilize a trading partner, please make them aware of this information.
- EOPS/835s and spanned claims — When a service for a migrating member spans the migration date, Tufts Health Plan will pay for services prior to the migration date and Harvard Pilgrim will pay for services on and after the migration date. There is no need for the provider to resend a claim; in an effort to minimize provider disruption, Point32Health is automatically entering the claim into our legacy organizations’ processing systems. However, we want you to be aware that providers will receive 2 Explanations of Payment/835s for spanned claims: one from each legacy organization. While your statements will reflect two different payers and claim numbers, the date of service and total charges will be identical on both statements. You’ll see that each organization will process their portion of the claim and deny the portion that the other legacy organization is responsible for. The EOP/835 will include messaging that says: “Dates of service following migration between THP and HPHC adjudication systems have been denied and transferred to the appropriate system for processing and adjudication. No further provider action needed” or “The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.”
- Obtaining medical drugs through specialty pharmacy — While OptumRx is the specialty pharmacy for pharmacy benefit drugs (though some plans may offer the opportunity for the member to use their current specialty pharmacy as well), please note that there was no change in contracted specialty pharmacies providing medical benefit drugs. For more information, please refer to this list of Specialty Pharmacies providing medical benefit drugs for Harvard Pilgrim members and this list for Tufts Health Plan members.
- Oral formula: If a migrating patient has an approved authorization for oral formula from Tufts, the authorization remains valid when the patient moves to their Harvard Pilgrim plan and the member can continue to receive their oral formula through a DME provider as they have been through the end date of the authorization. Please note, though, that from now through April 1, 2023, when requesting a new authorization for oral formula for a Harvard Pilgrim member, the member would receive the oral formula through the pharmacy, not the DME. As of April 1, 2023, that is changing, and Harvard Pilgrim members will receive oral enteral formulas through a DME provider. For details, refer to this article in the February 2023 newsletter.
- Behavioral health insourcing: We have included updated information on recruitment of behavioral health providers and continuity of care. If you are a behavioral health provider who is contracted with Tufts Health Plan, be on the lookout for a mailing with a contract amendment that will allow you to care for all our members, including Harvard Pilgrim members beginning on July 1, 2023. In most cases, there is no action for you to take when you receive your amendment packet; if action is required your packet will detail next steps. If you are a behavioral health provider with Optum/UBH who doesn’t currently participate in the Point32Health network, we encourage you to contact our Ancillary Behavioral Health Contracting team by email at AHCBehavioralHealth@point32health.org or by phone at 617-972-9400 x 43145 to join our network.
Look for additional updates in future issues of Insights and Updates for Providers and visit the Integration FAQ regularly.
Director, Provider Relations & Communications
Senior Manager, Provider Communications
Joseph O’Riordan, Jesse Salvato, Stephen Wong