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Back to Insights and Updates for ProvidersMarch 2023


INTEGRATION AND COMMERCIAL MIGRATION: REMINDERS AND UPDATES

All products

Please remember to visit our Integration FAQ for answers to common questions
about the combination of Harvard Pilgrim Health Care and Tufts Health Plan under
our parent organization, Point32Health.

Recently added information and reminders include:

 * Confirm the member’s product — As we continue to move members from Tufts
   Health Plan Commercial plans to Harvard Pilgrim Health Care commercial plans,
   it’s important to check member eligibility. We encourage you to ask for the
   member’s ID card and to use our secure provider portals to check member
   eligibility and benefits. For Harvard Pilgrim, use HPHConnect; For Tufts
   Health Plan members, visit the Tufts Health Plan secure provider portal.
 * Eligibility transactions (270/271s) — In an effort to minimize eligibility
   transaction rejections for migrating members and resubmissions, Point32Health
   is automatically returning eligibility information for migrating members with
   the correct Plan details. For example, if a request is sent to Tufts Health
   Plan for a member who recently migrated from Tufts Health Plan Commercial to
   Harvard Pilgrim Commercial, information returned will note the correct
   Harvard Pilgrim policy and benefit information. If you utilize a trading
   partner, please make them aware of this information.
 * EOPS/835s and spanned claims — When a service for a migrating member spans
   the migration date, Tufts Health Plan will pay for services prior to the
   migration date and Harvard Pilgrim will pay for services on and after the
   migration date. There is no need for the provider to resend a claim; in an
   effort to minimize provider disruption, Point32Health is automatically
   entering the claim into our legacy organizations’ processing systems.
   However, we want you to be aware that providers will receive 2 Explanations
   of Payment/835s for spanned claims: one from each legacy organization. While
   your statements will reflect two different payers and claim numbers, the date
   of service and total charges will be identical on both statements. You’ll see
   that each organization will process their portion of the claim and deny the
   portion that the other legacy organization is responsible for. The EOP/835
   will include messaging that says: “Dates of service following migration
   between THP and HPHC adjudication systems have been denied and transferred to
   the appropriate system for processing and adjudication. No further provider
   action needed” or “The claim/service has been transferred to the proper
   payer/processor for processing. Claim/service not covered by this
   payer/processor.”
 * Obtaining medical drugs through specialty pharmacy — While OptumRx is the
   specialty pharmacy for pharmacy benefit drugs (though some plans may offer
   the opportunity for the member to use their current specialty pharmacy as
   well), please note that there was no change in contracted specialty
   pharmacies providing medical benefit drugs. For more information, please
   refer to this list of Specialty Pharmacies providing medical benefit drugs
   for Harvard Pilgrim members and this list for Tufts Health Plan members.
 * Oral formula: If a migrating patient has an approved authorization for oral
   formula from Tufts, the authorization remains valid when the patient moves to
   their Harvard Pilgrim plan and the member can continue to receive their oral
   formula through a DME provider as they have been through the end date of the
   authorization. Please note, though, that from now through April 1, 2023, when
   requesting a new authorization for oral formula for a Harvard Pilgrim member,
   the member would receive the oral formula through the pharmacy, not the DME.
   As of April 1, 2023, that is changing, and Harvard Pilgrim members will
   receive oral enteral formulas through a DME provider. For details, refer to
   this article in the February 2023 newsletter.
 * Behavioral health insourcing: We have included updated information on
   recruitment of behavioral health providers and continuity of care. If you are
   a behavioral health provider who is contracted with Tufts Health Plan, be on
   the lookout for a mailing with a contract amendment that will allow you to
   care for all our members, including Harvard Pilgrim members beginning on July
   1, 2023. In most cases, there is no action for you to take when you receive
   your amendment packet; if action is required your packet will detail next
   steps. If you are a behavioral health provider with Optum/UBH who doesn’t
   currently participate in the Point32Health network, we encourage you to
   contact our Ancillary Behavioral Health Contracting team by email at
   AHCBehavioralHealth@point32health.org or by phone at 617-972-9400 x 43145 to
   join our network.

Look for additional updates in future issues of Insights and Updates for
Providers and visit the Integration FAQ regularly.

--------------------------------------------------------------------------------

Audrey Kleinberg
Director, Provider Relations & Communications

Annmarie Dadoly
Senior Manager, Provider Communications

Joseph O’Riordan, Jesse Salvato, Stephen Wong
Writers

Kristin Edmonston
Production Coordinator

Kristina Cicelova
Graphic Designer


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Insights and Updates for Providers Archives
 * March 2023
 * February 2023
 * January 2023

Insights and Updates for Providers (PDF versions)

Network Matters Issues (PDF versions)

Provider Update Issues (PDF versions)


IN THIS ISSUE:

March 2023
 * Tufts Health Together Accountable Care Organizations for 2023
 * Expanded access to CGP for advanced solid tumors
 * Harvard Pilgrim Provider Portal required fields update
 * Inactive account management for secure portal
 * Reminder: Telehealth Reimbursed at Pre-Pandemic Rate
 * Billing for telehealth
 * Reminder: MassHealth Unified Formulary
 * Requests for assisted reproductive technology services
 * Point32Health Medical Necessity Guideline updates
 * Abortion and abortion-related care update
 * Point32Health’s access to care standards
 * Members’ rights and responsibilities
 * Hydration therapy reimbursement update
 * Join us for a provider training
 * Updates and reminders

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