Back to Insights and Updates for ProvidersOctober 2023

Point32Health billing updates

Tufts Health Medicare Preferred PPO  |  Tufts Health Plan MCO/ACO  |  Tufts Health Plan Senior Care Options  |  Tufts Health Unify  |  Tufts Medicare Preferred HMO

Point32Health is making some updates to our billing requirements, all of which will be effective Dec. 1, 2023 for all Tufts Health Plan Medicare Advantage and Medicare-Medicaid products.

Occurrence codes
Point32Health will require providers billing services on UB-04 claim forms for the applicable products to bill occurrence codes and corresponding occurrence dates in the following manner:

  • An occurrence date must be present when billing an occurrence code
  • An occurrence code must be present when billing an occurrence date
  • A distinct occurrence code must not be billed more than once on a single claim

Occurrence codes and corresponding occurrence dates are located at Loop-2300/Segment HI/Element 1271 and Loop-2300/Segment HI/Element 1250, respectively, in the electronic 837 institutional claim format; for paper claims, occurrence codes and dates are reported in Form Locators (FL) 31-34. If any of this information is missing, the claim will be rejected and the provider will need to resubmit the claim in accordance with timely filing guidelines.

Condition codes: inpatient and skilled nursing facility (SNF) claims
In accordance with CMS requirements, we will require that a condition code of “40” be present on inpatient and SNF claims when the patient is transferred to another participating Medicare provider before midnight on the day of admission. Inpatient and SNF claims for members Tufts Health Plan Medicare Advantage and Medicare-Medicaid products not meeting this criterion will be rejected back to the submitting provider for correction and resubmission to Point32Health.

J-codes for injectable drugs
Effective Dec. 1, when J-codes for injectable drugs are submitted on claims for Tufts Health Unify, Tufts Health Plan MCO/ACO, Tufts Health Medicare Preferred HMO and PPO, and Tufts Health Plan Senior Care Options members without an accompanying quantity, appropriate National Drug Code (NDC) number, and unit of measurement code, these claims will be rejected back to the provider and must be resubmitted with the appropriate NDC code.

This is in accordance with criteria from the Executive Office of Health and Human Services and consistent with industry standard correct coding.

Audrey Kleinberg,
Director, Provider Relations & Communications

Annmarie Dadoly,
Senior Manager, Provider Communications

Joseph O’Riordan, Susan Panos, Stephen Wong,

Kristin Edmonston,
Production Coordinator

Kristina Cicelova,
Graphic Designer