Change Healthcare update: Timely filing limits and claim adjustment requirements to resume
Point32Health will return to our standard requirements for all lines of business regarding timely filing and claim adjustments, effective Sept. 1, 2024.
Insights and Updates for Providers
July 2024
Recovering negative balances
We have outlined reasons why a claim may be retracted, resulting in a negative balance, and ways to resolve a negative balance.
ConnectorCare plans – in-network coverage reminder
Harvard Pilgrim has joined Tufts Health Plan as a ConnectorCare issuer for 2024, expanding access to affordable health care coverage for thousands of Massachusetts residents.
Reminder: removal of certain prior authorization requirements
We would like to remind our providers of certain procedures and associated codes that no longer require prior authorization.
Coverage reminder – Community Behavioral Health Center services
We would like to remind providers of notification requirements and billing procedures related to Community Behavioral Health Center services.
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.
Removal of prior authorization requirements for certain procedures
We are removing prior authorization requirements from certain procedures and associated codes in a continued effort to administratively simplify providers’ experience.
2024 Home Care Seasonal Flu Vaccine Fee Schedule
Updates to Harvard Pilgrim’s standard home care seasonal influenza vaccine fee schedule will take effect on Aug. 1, 2024
Good Measures Healthy Weight program launches for members
Harvard Pilgrim Health Care has partnered with Good Measures to offer their Healthy Weight program to members with certain weight/nutrition-related conditions.
Pharmacy coverage changes
Read about updates to Point32Health’s Pharmacy program and our Pharmacy Medical Necessity Guidelines for Harvard Pilgrim and Tufts Health Plan.
Telehealth reimbursement update for BH services
Increased reimburse rate for BH telehealth services provided by non-BH providers.
Reminder: Value codes required on ESRD claims
Required value codes when billing for end-stage renal disease services.
Reminder: required billing for telehealth services
Please keep required billing practices for telehealth services in mind.
GIC product updates effective July 1
The 2024-2025 plan year for Harvard Pilgrim/GIC products begins July 1.
Reimbursement update: Behavioral Health Integration services
Point32Health is expanding coverage for Behavioral Health Integration services.
New HEDIS tip sheet for Prenatal Immunization Status
We’ve developed a new HEDIS® tip sheet for the PRS-E measure.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Updates to medical drug claims editing logic
We’re updating medical drug claims editing logic to remove certain edits.
Utilization management update for home health care services
We’re updating home health care UM requirements for quality and efficiency.
MNG update: Non-Emergency Medical Transportation
Integrated Point32Health Medical Necessity Guidelines for Non-Emergency Medical Transportation.
Standard form for Applied Behavior Analysis prior authorization requests
A standard authorization form for ABA services has been adopted.
Complex Care Management services
Point32Health provides complex care management services individually tailored to patients.
About Our Chronic Condition Management programs
Point32Health’s chronic condition management programs reinforce clinician treatment plans.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Reminder: trastuzumab biosimilar strategy
Reminder of our biosimilar strategy for trastuzumab oncology drugs.
Oral formula authorization request update
Clarification on how to request authorization for oral formula.
Reminder: Step therapy protocols and exceptions
Massachusetts law now requires mandatory exceptions in step therapy protocols.
Coverage update for mental health wellness examinations
Annual mental health wellness exams covered at no cost for certain members.
Billing for lead screening
Lead screenings for ages 0-6 years covered with no member cost share.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Expanded access to CGP for advanced solid tumors
We’re reminding providers of our comprehensive genomic profiling coverage and authorization process.
Harvard Pilgrim commercial fee schedule in effect April 1
Reminder: Harvard Pilgrim’s updated commercial fee schedule takes effect April 1.
Oral formula authorization request update
Change coming to the way oral formula is requested on authorizations.
Use code A4287 for coverage of breast milk storage bags
Use code A4287, not K1005, for coverage of breast milk storage bags.
Clarification: Prior authorization on insulin infusion pumps
Authorization required for insulin pumps which work in conjunction with a CGM device.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
2024 Physician Group Honor Roll announced
53 physician groups named to Harvard Pilgrim’s Physician Group Honor Roll.
Behavioral Health hub for members
New resource for Harvard Pilgrim members regarding behavioral health topics.
Important tips to minimize denials
Tips for a smooth Harvard Pilgrim commercial migration process and accurate claims reimbursement.
Ovia Health’s Family & Maternal Health Solutions
Ovia Health now available to Tufts Health Together and Tufts Health RITogether members.
Maine mandate and new coverage for donor breast milk
Beginning Jan. 1, donor breast milk will be covered for eligible infants in Maine.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Connecticut market exit reminder
Reminder about Harvard Pilgrim Health Care’s withdrawal of fully insured commercial products in Connecticut as of Jan. 1, 2024.
Crisis resource reminder for Massachusetts members
Learn more about Community Behavioral Health Center resources available in Massachusetts.
Maine mandates and new coverage
Commercial medical necessity guideline updates to align with recent legislation in Maine.
Pharmacy coverage changes
Pharmacy coverage changes for various Point32Health products.
Reminder and clarification of billing requirements for Spravato
Reminder and clarification on billing for Spravato nasal spray.
Urine Drug Testing Payment Policy integration
Urine Drug Testing coverage and payment policy updates.
Updates on Rhode Island for 2024
Read about our 2024 commercial migration, new product, and more!
New ICD-10 code for HIV PrEP
HIV PrEP billing requirements and new ICD-10 code.