Back to Insights and Updates for ProvidersJune 2024

Removal of prior authorization requirements for certain procedures

Harvard Pilgrim Health Care Commercial  |  Tufts Health Direct  |  Tufts Health One Care  |  Tufts Health Plan Commercial  |  Tufts Health RITogether  |  Tufts Health Together

As we look to the future and continually evaluate ways to streamline the delivery of high-quality care — and effectively support our provider partners by minimizing your administrative burden — one of Point32Health’s focal priorities is on assessing the value and necessity of our prior authorization requirements.

We announced in the April issue of Insights and Updates to Providers that we no longer require prior authorization for the initial 30 days of service for home health care for Commercial Harvard Pilgrim Health Care and Tufts Health Plan members. In a continuation of these efforts, we are removing prior authorization requirements from the following procedures and associated codes for our Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, and Tufts Health One Care members, effective for dates of service beginning July 1, 2024:

  • Laparoscopic Cholecystectomy (CPT 47562, 47563, 47564)
  • Transcervical Radiofrequency Ablation of Uterine Fibroids (CPT 58580)
  • Prostatectomy, Transurethral Resection (TURP) (CPT 52601, 52630, 52648)

With the removal of prior authorization requirements from these services, the following Medical Necessity Guidelines will be retired:

  • Medical Necessity Guidelines for Cholecystectomy, Laparoscopic
  • Medical Necessity Guidelines for Transcervical Radiofrequency Ablation of Uterine Fibroids

In addition, we are updating our Procedures for the Treatment of Benign Prostatic Hypertrophy Medical Necessity Guidelines to note that prior authorization is no longer required for TURP and to remove the related codes.

Please look to future issues of Insights and Updates for Providers for more information on this ongoing initiative to decrease your administrative burden and expedite care for our members, where possible.

*Editor’s note: correction made 6.3.2024 to clarify that TURP applies to transurethral resection of the prostate. 

Audrey Kleinberg,
Director, Provider Relations & Communications

Annmarie Dadoly,
Senior Manager, Provider Communications

Joseph O’Riordan, Susan Panos, Ellen Gustavson, Ryan Francis, Stephen Wong,

Kristin Edmonston,
Production Coordinator

Kristina Cicelova,
Graphic Designer