Effective for dates of service beginning Dec. 1, 2026, Point32Health will introduce extensive enhancements to our sleep management program intended to streamline utilization management for sleep studies and sleep DME (e.g., positive airway pressure [PAP] devices, PAP supply/resupply) across multiple lines of business. 

Updates include:

  • EviCore — our current sleep benefit management vendor for Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, and Tufts Medicare Preferred — will assume management of prior authorization for sleep‑related services for Harvard Pilgrim Health Care Commercial and Tufts Health RITogether members, replacing the current mix of internal processes and vendor partnerships.
  • The sleep studies program presently administered by Evolent for Harvard Pilgrim Commercial members will be retired in conjunction with this shift to EviCore. 
    • Services such as cardiac diagnostic tests and interventional procedures; high-tech diagnostic imaging; select joint procedures; spine surgery and cervical spine procedures; and outpatient interventional spine pain management services will continue to be reviewed by Evolent.
  • Notification will no longer be required through EviCore for sleep studies and sleep DME for Tufts Medicare Preferred members. 

These updates are designed to improve clinical alignment, ensure consistent application of evidence‑based guidelines, and provide a smoother experience for providers and members.

Harvard Pilgrim Commercial: transition to EviCore

Currently, Evolent manages sleep study utilization management for Harvard Pilgrim Commercial members, and sleep DME is managed internally by Harvard Pilgrim. Under the new model, all sleep studies, PAP devices, and PAP supply/resupply will transition to EviCore.

Notable impacts include:

  • EviCore’s national guidelines will be utilized for medical necessity criteria.
  • Home sleep tests will no longer be subject to prior authorization or notification requirements.
  • CPT/HCPCS codes for sleep studies will remain otherwise the same.

PAP device and PAP supply/resupply experience changes

Harvard Pilgrim’s current notification‑only process for PAP devices will be replaced by EviCore’s prior authorization requirement and ongoing medical review.

Under EviCore:

  • Medical necessity review applies to initial and replacement devices and supplies.
  • Objective PAP usage data is required for continuation, as managed through EviCore’s TherapySupport program, which allows for compliance data to be automatically transmitted to EviCore for a streamlined resupply authorization process.
  • Prior authorization will also be required through EviCore for PAP supply/resupply (masks, tubing, filters, humidifier components, and other accessories).
    • Providers must demonstrate member compliance and clinical benefit to support ongoing resupply.

Tufts Health RITogether sleep program transition

While many of EviCore’s criteria align closely with our existing policies for Tufts Health RITogether, providers should expect:

  • More explicit criteria for split‑night studies and repeat testing. 
  • A stronger emphasis on home sleep apnea testing (HSAT) when appropriate, which will not be subject to prior authorization requirements. 
  • New PAP therapy, compliance monitoring, and PAP supply/resupply requirements.

Requesting authorization and more information

You can register and log in to the secure EviCore website at EviCore.com or call 888-511-0401 to request prior authorization. 

Updates will be incorporated into our applicable Provider Manuals and the vendor programs section of our provider website in alignment with the Dec. 1 effective date. Please note that EviCore will begin accepting prior authorization requests on Nov. 16. 2026 for dates of service beginning Dec. 1.

You can find additional information and useful reference materials such as an FAQ, Quick Reference Guide, and CPT code list on this provider resource site, which EviCore has developed specifically for Point32Health providers.

Training sessions

EviCore will also be hosting the following virtual Point32Health Sleep Management Provider Orientation sessions, designed to support providers and their staff in understanding and navigating the new program requirements:

  • Nov. 17, 2026 – 12:00 p.m. – 12:30 p.m. EST
  • Nov. 19, 2026 – 2:00 p.m. – 3:00 p.m. EST
  • Nov. 23, 2026 – 11:00 a.m. – 12:00 p.m. EST
  • Dec. 3, 2026 – 10:00 a.m. – 11:00 a.m. EST
  • Dec. 8, 2026 – 11:00 a.m. – 12:00 p.m. EST
  • Dec. 10, 2026 – 1:00 p.m. – 2:00 p.m. EST

These training opportunities will include an overview of the prior authorization process and information on how to access and use resources on the EviCore website, as well as a live question-and-answer session. 

Advance registration is required for these online orientation sessions, which you can do here. If you are unable to attend the live session, a copy of the presentation and other related materials will be available on EviCore’s Point32Health provider resource site. We encourage you and your office staff to take advantage!