Insights and Updates for Providers

We’re making a change to our claim adjudication process for ancillary services billed in connection with services requiring prior authorization when the authorization is not obtained.

We’re introducing prior authorization requirements for spine, joint, oncology, and home health services for our Harvard Pilgrim/Iron Workers union shared administration plan.

We’re offering a reminder that the 2026-2027 plan year for our Harvard Pilgrim/Group Insurance Commission products begins on July 1, 2026.

We’re updating how we process authorization requests for outpatient home care and hospice and palliative care services for Harvard Pilgrim Commercial products in Maine.

Services for Tufts Health Together with Cambridge Health Alliance (CHA) ACO members will require primary care referrals for specialty services outside of the CHA network.

All providers who render EVV eligible services are required to use an EVV system to verify that certain services have been delivered as billed.

Submit all applicable outstanding claims, claims corrections, and claims appeals for services by July 9 to meet MassHealth’s health plan encounter data deadline.

We will no longer cover the specified drugs for the treatment of obesity or overweight for members of certain plans.

We will no longer provide coverage for Dexcom continuous glucose monitors (CGMs) and their accompanying supplies — including new starts and those with previous approvals.

You can refer to this chart to review changes and updates related to Point32Health's Pharmacy Medical Necessity Guidelines.