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 |
| Peer Recovery Coach | Harvard Pilgrim Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health One Care | 1/1/2026 | Scope of MNG expanding to newly apply for Harvard Pilgrim Commercial members (in Massachusetts only). In accordance with MA bill H.5143 (An Act relative to treatments and coverage for substance use disorder and recovery coach licensure), CPT code H2016-HM (comprehensive community support services, per diem) will be covered with no prior authorization or notification requirements. Also updated Outpatient Behavioral Health & Substance Use Disorder Payment Policy to include billing instructions for Peer Recovery Coach and Peer Recovery Support Navigators for pregnant and postpartum women. |
| Long-term Supports and Services | Tufts Health One Care, Tufts Health Plan Senior Care Options | 1/1/2026 | MNG updated to reflect that, in support of Personal Care Attendant Bulletin 17 (and associated regulatory guidance from MassHealth), we will reimburse personal care assistance (PCA) providers according to a differential payment rate for complex care tasks for members who require physical assistance with digital rectal stimulation or an enteral feeding tube (G and/or J tube). These PCA services are billed using an add-on to differentiate between PCA and PCA for complex care (HCPCS code T1019 with modifier TG). The differential payment rate will be offered when the eligibility criteria outlined in the bulletin are met. |
| Carelon medical benefits management program | Harvard Pilgrim Commercial | 1/1/2026 | A number of codes/services will be newly covered with prior authorization through our medical benefits management program with Carelon. Refer to this document for the full list. |
| Home Health Care | Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 12/1/2025 | Minor criteria updates for clarity and alignment with MassHealth guidelines. In addition, we will now cover CPT codes 99058 and 99509 with prior authorization. |
| Noncovered Investigational Services | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 12/1/2025 | MNG updated to reflect that the Vivally bladder control therapy device and Lantrida (allogeneic pancreatic islet cellular therapy) are not covered. |
| Children’s Behavioral Health Initiative Family-based Intensive Treatment | Tufts Health Together | 10/1/2025 | Minor update to discharge criteria. |