Back to Insights and Updates for ProvidersNovember 2023

New and updated Medical Necessity Guidelines

All products

Effective for dates of service beginning Jan. 1, 2024, Point32Health has developed some new Medical Necessity Guidelines (MNGs), and made updates to existing ones.

New MNG for Noncovered Investigational Services

In the interest of our ongoing integration work as a combined organization, Point32Health is continually assessing opportunities for further alignment of clinical policies and processes, including coverage and coding. In support of this work, we’ve merged our existing Harvard Pilgrim New Technology Assessment and Non-Covered Services Medical Necessity Guidelines and Tufts Health Plan Noncovered Investigational Services Medical Necessity Guidelines into one new, combined policy: Point32Health Noncovered Investigational Services Medical Necessity Guidelines (Harvard Pilgrim, Tufts Health Plan).

With the creation of the combined MNG, effective Jan. 1, we are making extensive coding updates to streamline the provider experience related to our legacy Harvard Pilgrim and Tufts Health Plan products. For each line of business, a number of codes will no longer be covered, some will be newly covered, some codes will be removed because they are no longer relevant, etc. Please refer to the new MNG for complete information.

New MNG for home accessibility adaptations

We’ve developed new medical necessity guidelines related to home accessibility adaptations for Tufts Health Together, Tufts Health Unify (soon to be Tufts Health One Care), and Tufts Health Plan Senior Care Options (SCO).

Home accessibility adaptations — which are reported using HCPCS code S5165 (Home modification, per service) and will require prior authorization — are physical modifications to a patient’s home that are necessary to ensure the health, welfare, and safety of the patient or that enable the patient to function with greater independence in the home, as defined by the Commonwealth of Massachusetts Program Regulations for Home- and Community-Based Services, 130 CMR 630.000.

Please refer to the newly developed Medical Necessity Guidelines for Home Accessibility Adaptations for complete clinical coverage criteria, limitations, and other information.

Behavioral health level of care updates

Point32Health utilizes InterQual criteria, as well as criteria from the American Society of Addiction Medicine (ASAM) for determining medical necessity for behavioral health levels of care. We’re expanding the use of those criteria to apply for a number of other services.

For complete information on which criteria will apply for which services/products, please refer to our updated Medical Necessity Guidelines for Behavioral Health Inpatient and 24 Hour Level of Care Determinations (Harvard Pilgrim, Tufts Health Plan) and Behavioral Health Level of Care for Non-24 Hour/Intermediate/Diversionary Services (Harvard Pilgrim, Tufts Health Plan).

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