Reminder: balance billing prohibited by Point32Health

We would like to remind providers who serve our Harvard Pilgrim Health Care and Tufts Health Plan members that Point32Health does not allow balance billing of our members, which is the attempted collection of fees for services other than a member’s applicable cost share amount.

You can find more detailed information about our billing policies and procedures, including the prohibition of balance billing, in the following sections of the Harvard Pilgrim and Tufts Health Plan Provider Manuals:

• Harvard Pilgrim:
  • Collecting Member Payment policy located in the Member Care section of the Commercial Provider Manual
  • Billing Members policy in the Billing and Reimbursement section of the Stride^SM (HMO)(HMO-POS) Medicare Advantage Provider Manual
• Tufts Health Plan:
  • Referrals, Prior Authorizations and Notifications section of the Commercial Provider Manual
  • Claims Requirements, Coordination of Benefits and Dispute Guidelines section of the Tufts Health Public Plans Provider Manual

Rhode Island Medicaid billing reminder

Recent correspondence from the Rhode Island Executive Office of Health and Human Services (RI EOHHS) to health plans offered a reminder that balance billing is prohibited in Medicaid and our providers are not permitted to charge Medicaid beneficiaries (e.g., Tufts Health RITogether members) for covered services.

As outlined in the Charging Medicaid Beneficiaries section of RI EOHHS’ Rhode Island Medicaid Provider Reference Manual, the Medicaid program reimbursement is considered payment in full, and the provider is not permitted to seek further payment from the beneficiary in excess of the Medicaid program rate.

Per the Rhode Island EOHHS correspondence, providers who continue to balance bill will not be permitted to participate in Rhode Island Medicaid.

Audrey Kleinberg,
Director, Provider Relations & Communications

Annmarie Dadoly,
Senior Manager, Provider Communications

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