Insights and Updates for Providers

Members who are currently receiving a targeted immunomodulator for a dermatological indication will soon be required to obtain reauthorization to maintain continued access to therapy.

Effective June 1, 2026, providers will be required to submit a Medicare opt-out form with their claim in applicable instances.

We encourage providers to use our internal utilization management and claims appeal processes for faster, expert reviewed resolution of coverage and payment disputes.

The Provider-Level Balance segment on the 835 ERA helps providers trace negative balances, understand offsets, and reconcile payments, refunds, and adjustments.

To ensure that your claims are accepted for processing, update your billing systems to reflect the new member ID numbers for Tufts Health One Care members.

We want to make PCPs who care for Rhode Island members aware of recent Rhode Island legislation related to prior authorizations.

At this time, we are experiencing a high volume of claims appeals, which has impacted processing timeframes for some lines of business.

Beginning June 1, 2026, new‑to‑market pharmacy drugs will be excluded from coverage until clinical review, with limited exceptions allowed.

If you typically receive reimbursement from Harvard Pilgrim Health Care or Tufts Health Plan on Fridays via electronic funds transfer, we want to make you and your office staff aware of three upcoming bank holidays which will fall on Fridays, resulting in slight payment delays.

Point32Health is updating our policy related to the reimbursement of preventive medicine services when billed with screening and/or other evaluation and management (E&M) services.