2025 Physician Group Honor Roll announced
We would like to congratulate the 56 physician groups in Harvard Pilgrim’s Commercial network named to our 23rd annual Physician Group Honor Roll.
Insights and Updates for Providers
January 2025
Insourcing chronic kidney disease care management
Point32Health will be insourcing chronic kidney disease (CKD) care management services for Harvard Pilgrim Health Care and Tufts Health Plan Commercial members beginning Jan. 1, 2025.
Our contact information
We want to highlight some key contact information and resources for providers contacting us for support, such as our online provider portals and Provider Services team.
About our products with the Painters and Iron Workers Unions
Harvard Pilgrim is pleased to offer shared administration plans for the Painters & Allied Trades District Council No. 35 and the Iron Workers District Council of New England/Iron Clad unions.
Use our secure HPHConnect portal for speedy self-service
We encourage providers and office staff to use our secure HPHConnect portal to conduct a variety of self-service transactions for Harvard Pilgrim Health Care Commercial members.
Continued stay and inpatient level of care reviews
We’re sharing a reminder regarding continued stay reviews for DRG case rate admissions, and an update to our level of care review process for elective inpatient surgical procedures.
New Payment Policy and billing for hospital at home
Point32Health has developed a Payment Policy for Inpatient Hospital Admissions, which includes billing instructions for hospital at home care, which Point32Health reimburses for contracted providers when medically necessary.
HEDIS MY2024 medical record requests
As required by NCQA and CMS, Point32Health will send HEDIS MY2024 medical record requests via mail to providers for all Point32Health products beginning in February 2025.
New pilot program offers virtual cardiac rehabilitation
Tufts Medicare Preferred members in Massachusetts can now choose to participate in a pilot program offered in collaboration with Movn Health, which provides telehealth cardiac rehabilitation following a heart event.
Living Well – 2025 program offerings for providers and members
We’re pleased to announce enhancements to our virtual Living Well program for the year ahead, including webinar series on a number of fascinating topics.
PPACA coverage policy updates for 2025
We’ve made minor updates to the Harvard Pilgrim Patient Protection and Affordable Care Act Policy, and we’ve developed equivalent policies for Tufts Health Plan Commercial and Direct.
CAQH Provider Data Portal updates and upcoming training
If you utilize the CAQH Provider Data Portal to review and update your provider directory information, you’ll soon see some additional required fields.
Help us keep directory information up to date
Please review and revalidate your practice information every 90 days to ensure accuracy of our Provider Directory, and notify Point32Health in advance of any changes.
Add-on payments for corrective mobility system timely repairs
In support of guidance from MassHealth and the Executive Office of Health and Human Services, we will provide an additional add-on payment for corrective mobility system timely repairs.
Billing for routine eye care services
As a reminder for optometrists and ophthalmologists who treat Tufts Health Together members, routine eye exams should be reported using CPT codes 92002, 92004, 92012, and 92014.
Coverage for inpatient donor human milk
As of Nov. 21, 2024, Point32Health will now cover medically necessary inpatient donor human milk and donor human milk-derived products for members of certain Massachusetts plans.
Billing for all-inclusive clinic visits
Point32Health has updated our All-Inclusive Clinic Visit (HCPCS Code T1015) Payment Policy to reflect a billing change for Tufts Health Plan Senior Care Options (SCO) Medi members only.
Point32Health Medical Necessity Guideline updates
Refer to this chart to review changes and updates to Point32Health’s Medical Necessity Guidelines, information about newly developed MNGs, and more.
Prior authorization requirements for cardiac services
Effective for dates of service beginning March 1, 2025, Point32Health and Evolent are adding prior authorization requirements for a number of additional cardiac services.
Point32Health medical drug program updates
Refer to this chart to review changes and updates to Point32Health’s medical drug program, including information about prior authorization, coverage updates, and more.
Prior authorization update for administration of CAR T-cell drugs
In response to provider feedback, we will no longer require prior authorization for the preparation and administration of the following CAR T-cell therapy medications.
Pharmacy coverage changes
We have made updates to our pharmacy program; please refer to the Pharmacy Medical Necessity Guidelines page on our website for more details.
Updated billing instructions for Adult Day Health providers
Point32Health is making an update to the claims submission process for home- and community-based services, effective for dates of service beginning March 1, 2025.