Insights and Updates for Providers

We anticipate making Point32Health functionality available through Availity Essentials in mid-November for many electronic transactions. 

New interoperability capabilities will offer more connected ways to access certain payer-held information, support care coordination, and complete some administrative tasks more efficiently.

Point32Health will introduce extensive enhancements to our sleep management program intended to streamline utilization management for sleep studies and sleep DME. 

We’re offering details about updates to our Obstetrics/Gynecology Payment Policy, which will reflect the CPT 2027 code set for maternity care services. 

We’re adjusting our Provider Service Center hours to better accommodate provider needs and offer enhanced call support when you need it most.

Review Pharmacy Medical Necessity Guidelines updates as well as drug status and formulary changes for the 2027 plan year.

We will transition administrative operations of the US Family Health Plan to BrightonOne and its subcontractors, effective Jan. 1, 2027.

Formulary changes regarding SGLT2 inhibitor drugs are coming Jan. 1, 2027 for Commercial large group members.

For certain members on targeted immunomodulator medications, existing prior authorizations will terminate on Dec. 31, 2026 and reauthorization will be required.

We’re mailing letters to certain Harvard Pilgrim members outlining potential at-home colorectal cancer screening options as possible alternatives to a colonoscopy.