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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

April 2017

Highlights
CVS Specialty Becomes New Preferred Specialty Pharmacy in July

Harvard Pilgrim is pleased to announce that we will be working with CVS Specialty pharmacy as our preferred specialty pharmacy, effective July 1, 2017.

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Updated Medical Review Criteria for Rituxan

Effective for services authorized on or after April 1, 2017, Harvard Pilgrim is updating its medical review criteria for Rituxan.

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Harvard Pilgrim’s Maximum Units Per Day Policy

Effective July 1, 2017, Harvard Pilgrim will begin utilizing the Centers for Medicare and Medicaid Services’ (CMS’s) maximum unit values— or medically unlikely edits (MUE) — for most CPT and HCPCS codes, where available.

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Payment Policy Update: Billing Consultation Codes 99241-99245

Effective for dates of service beginning June 15, 2017, Harvard Pilgrim will no longer reimburse for consultation services (CPT codes 99241 – 99245) when the same provider has previously billed for the same or a similar condition, for the same member in the previous 12 months.

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Payment Policy Update: Pelvic/Transabdominal and Transvaginal Ultrasounds

Effective for dates of service beginning June 15, 2017, based on rationale from the American Congress of Obstetricians and Gynecologists (ACOG), Harvard Pilgrim will no longer separately reimburse transabdominal ultrasounds (CPT codes 76801-76812) or pelvic ultrasounds (CPT codes 76856, 76857) when performed during the same session as a transvaginal ultrasound (CPT codes 76830 or 76817).

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Network Matters Archives

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HPHCURRENT EVENTS

CVS Specialty Becomes New Preferred Specialty Pharmacy in July

Boston Medical’s Industry-Leading Transgender Care and Provider Education

Behavioral Health to Be Offered Via Telemedicine

CLINICIAN CORNER

Updated Medical Review Criteria for Rituxan

Bronchial Thermoplasty Now Covered With Prior Authorization

Complex Case Management Services

Disease Management Programs Reinforce Physician Treatment Plans

P&T Committee Updates

Identifying and Treating Postpartum Depression

OFFICE ASSISTANT

Harvard Pilgrim’s Maximum Units Per Day Policy

Payment Policy Update: Anatomical Modifiers

Payment Policy Update: Billing Consultation Codes 99241-99245

Payment Policy Update: Fetal Anatomical Ultrasound

Payment Policy Update: Pelvic/Transabdominal and Transvaginal Ultrasounds

HPHConnect: Inactive Account Management

PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator