The chart below identifies updates to our Medical Necessity Guidelines. For additional details, refer to the Medical Necessity Guidelines page on our Point32Health provider website, where you can find coverage and prior authorization criteria for our Harvard Pilgrim and Tufts Health Plan lines of business.
| Updates to Medical Necessity Guidelines (MNG) | |||
| MNG Title | Products Affected | Effective Date | Summary |
| Noncovered Investigational Services | Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plan | Feb. 1, 2024 | The following services have been added to the Noncovered Investigational Services MNG and will no longer be covered:
|
| Noncovered Investigational Services | Tufts Health Together | Feb. 1, 2024 | AEYE Diagnostic Screening (AEYE-DS) (CPT code 92229) is now covered without prior authorization for Tufts Health Together members. |
| Home and Community Based Services | Tufts Health RITogether | Feb. 1, 2024 | In support of guidance from the Rhode Island Executive Office of Health and Human Services (EOHHS), the services/codes outlined on this MNG will no longer require prior authorization for RITogether members, and the MNG will serve as a coverage guideline.
A number of physical, occupational and speech therapy codes have been removed from the MNG and can be found on the Home Health Care Services for Tufts Health Together, Tufts Health RITogether, and Tufts Health One Care MNG. |
| Applied Behavioral Analysis including Early Intervention for RITogether | Tufts Health RITogether | Feb. 1, 2024 | In support of guidance from the Rhode Island EOHHS, prior authorization is no longer required for applied behavioral analysis services. In addition, an autism diagnosis is no longer required for coverage of these services. Language and coding on the MNG have been updated to reflect this change. |
| Behavioral Health: Evidence-Based
Practices (EBP) |
Tufts Health RITogether | Feb. 1, 2024 | Prior authorization is no longer required, and the MNG will be maintained as a coverage guideline. |
| Behavioral Health Enhanced Outpatient
Services (EOS) |
Tufts Health RITogether | Feb. 1, 2024 | Prior authorization is no longer required, and the MNG will be maintained as a coverage guideline. |
| Personal Assistance Services & Supports (PASS) | Tufts Health RITogether | Feb. 1, 2024 | Prior authorization is no longer required, and the MNG will be maintained as a coverage guideline. |
| Assisted Reproductive Technology Services – Massachusetts Products
Assisted Reproductive Technology Services – Maine Products Assisted Reproductive Technology Services – New Hampshire Products Assisted Reproductive Technology Services – Rhode Island Products |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Direct | Feb. 1, 2024 | Minor update to limitation language for clarification regarding donor eggs for ART services.
|
| Hospice and Palliative Care Services | Harvard Pilgrim commercial | Feb. 1, 2024 | MNG updated with clarifying information. |
| Therapeutic Lenses | Tufts Health Plan commercial, Tufts Health Public Plans | Feb. 1, 2024 | MNG will be retired, and prior authorization will no longer be required for CPT codes 92071 and 92072 for Tufts Health Plan commercial and Tufts Health Public Plans. These codes will continue to be covered without prior authorization for Harvard Pilgrim commercial plans, and reimbursement guidance can be found on Harvard Pilgrim’s Vision Services Payment Policy. (Reimbursement may vary depending on the member’s benefit.) |
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