As you know, Harvard Pilgrim Health Care and Tufts Health Plan combined under the parent organization Point32Health on Jan. 1, 2021. We are confident that this combination will enable us to keep high-quality health care accessible and affordable, while at the same time investing in programs and initiatives that enhance the quality of care and the overall experience we provide our customers. As a newly combined organization, we want to keep our network providers aware of the work we have done in transitioning our technologies, processes, and products — as well as share our plans for what’s ahead.
What product changes are planned?
As part of our integration, Point32Health has been evaluating the products offered by our legacy Harvard Pilgrim Health Care and Tufts Health Plan brands, as well as market needs. Some things will remain the same. You can expect us to continue to offer a broad range of comprehensive plans that improve the well-being of members and their families, guiding them on their journey to better health outcomes. You’ll also continue to see the Harvard Pilgrim Health Care and Tufts Health Plan brands in the market, as the health plans of our members.
You’ll notice some changes too. We have begun integrating certain products, which we believe will allow us to offer more innovation, more access, and an even better experience for members, employers, and brokers in our service area. We anticipate this integration work to continue throughout 2023 and 2024:
- Stride (HMO) Medicare Advantage: As of Jan. 1, 2022, we offer the 5-Star Medicare Advantage Plan — Tufts Medicare Preferred — as the Medicare Advantage option for seniors in Massachusetts. While we no longer offer Harvard Pilgrim Health Care’s StrideSM (HMO) Medicare Advantage Plans in Massachusetts and Maine, we do continue to offer Stride in certain counties in New Hampshire. We also continue to offer Medicare Supplement Plans in Massachusetts, Maine, and New Hampshire.
- Commercial products: Beginning on Jan. 1, 2023, Tufts Health Plan’s employer group clients and members of individual and small group products (including those serviced by our intermediary partners) in Massachusetts will begin transitioning to the Harvard Pilgrim product portfolio, as the Commercial Markets business moves toward a more unified product portfolio. These transitions will occur on the health plan renewal date. Additional segments of Tufts Health Plan employer clients and members will migrate in 2024. More details will be shared in the future. With these product migrations, certain Tufts Health Plan products will no longer be offered, and comparable Harvard Pilgrim products will be offered to these employer group clients, as well as individual members. We will continue to offer our Harvard Pilgrim Commercial products in Maine and New Hampshire.
- Tufts Medicare Complement: Beginning on Jan. 1, 2023, members of Tufts Medicare Complement plans (group Medicare) will also migrate to Harvard Pilgrim’s Medicare Enhance product.
In support of a smooth transition, we will be communicating extensively with members, brokers, employers, and providers, sending broad-based updates, as well as direct and individual communications to explain these changes. These communications are being delivered through a variety of channels: as part of renewal processes, via newsletters, and direct to employer and member updates. Provider groups that are also employer clients should contact their account management team with any questions.
Will you offer products under the name “Point32Health” in the market?
No, while we are officially one organization, our heritage brands and products will remain in the market. We will continue to offer plans under our Harvard Pilgrim Health Care and Tufts Health Plan legacy brands; the Point32Health name is not being actively marketed as a consumer brand.
Will all Commercial members of Tufts Health Plan be moved to a Harvard Pilgrim Health Care Commercial product all at once?
No, Commercial employer group clients and members will migrate to Harvard Pilgrim products throughout a staggered and thoughtful timeline — beginning on Jan. 1, 2023. This approach focuses on minimizing disruption and aligns to core renewal cycles for the business as well as specific employer groups.
Our Commercial account management team will have direct conversations with provider groups that are also employer group clients to determine optimal timing and address any migration concerns, as needed.
We anticipate that the combination of our Commercial products will continue through Jan. 2025.
How will I recognize if a member has changed plans?
Every member who has a medical plan change will receive a new member ID card prior to their effective date, as part of our standard open enrollment and renewal processes. Members are always instructed to present any new member ID card that they receive to their providers to ensure accuracy in billings, claims, and payments.
In addition, we encourage your office to check eligibility and benefits using our online provider tools. You can check member eligibility and benefits for Harvard Pilgrim Health Care members using our HPHConnect portal. For more options, refer to the Determining Eligibility Policy in the Harvard Pilgrim Health Care Commercial Provider Manual. To check member eligibility and benefits for Tufts Health Plan members, visit the Tufts Health Plan secure provider portal or refer to the relevant Provider Manual.
Can I call either Provider Service Center with questions?
Please continue to call the member’s appropriate heritage organization with questions — please refer to the member’s ID card for the Provider Service Center contact information. For example, if for the service date you are inquiring about the member is enrolled in a Harvard Pilgrim Health Care plan, please contact the Harvard Pilgrim Health Care Provider Service Center; if the member is enrolled in a Tufts Health Plan product for that service date, please contact the Tufts Health Plan Provider Service Center.
Will there be any changes to how I bill for service?
You should continue to follow the guidelines for the plan/legacy brand that is in effect for the member at the time of service. Please refer to the appropriate provider website for details on billing and claims submission: Tufts Health Plan provider website or Harvard Pilgrim Health Care provider website. In future updates, we will provide additional details related to claims submission in the event that the member’s care spans the migration date.
Are you aligning your Payment Policies?
Throughout this year, we have been reviewing and assessing Payment Policies for each legacy organization with the intent to align them for greater ease and efficiency. The majority of our Payment Policies have undergone review, and in cases where significant updates were made, we announced those changes via our monthly provider newsletters. We will have completed review of all remaining guidelines by January 2023 and will continue to provide notice of substantive changes in our provider newsletters. Please keep in mind that Payment Policies may vary based on product line and related coverage mandates (for example, Commercial Payment Policies may differ from Payment Policies for Medicare or Public Plans products).
Will Harvard Pilgrim Health Care and Tufts Health Plan be using the same pharmacy benefit manager in 2023?
Yes, as we announced in September 2021, Point32Health selected OptumRx as the pharmacy benefit manager (PBM) for all Tufts Health Plan and Harvard Pilgrim plans, effective Jan. 1, 2023. The new collaboration between Point32Health and OptumRx further broadens the long-term strategic relationships the legacy Harvard Pilgrim Health Care and Tufts Health Plan brands have already fostered with Optum.
What are the benefits of this collaboration?
The multi-year agreement will provide PBM solutions that will enhance pharmacy services and deliver improved pricing for Harvard Pilgrim Health Care and Tufts Health Plan members.
What services will OptumRx provide?
OptumRx will support the delivery of convenient and affordable access to prescription medications to Harvard Pilgrim Health Care and Tufts Health Plan members through a comprehensive retail, specialty, and mail-order pharmacy network that includes more than 67,000 pharmacies nationwide, including all major chains such as CVS.
OptumRx will be administering pharmacy claims payment, providing specialty pharmacy and mail-order services, and managing the pharmacy network across both legacy organizations — for a more streamlined, efficient provider experience.
What are the key differences for providers?
The following chart notes the key changes for each legacy organization:
Tufts Health Plan
|Before Jan. 1, 2023
||Starting Jan. 1, 2023|
|Pharmacy Benefit Manager
Mail Order Services
Pharmacy Claims Processing
|Specialty Pharmacy||CVS Specialty||Optum Specialty|
|Prescription Drug Program (formularies, pharmacy medical necessity guidelines, appeals)||Point32Health||Point32Health (no change)|
|Utilization Management Determinations||Point32Health||Point32Health (no change)|
Harvard Pilgrim Health Care
|Before Jan. 1, 2023
||Starting Jan. 1, 2023|
|Pharmacy Benefit Manager
Mail Order Services
Pharmacy Claims Processing
|OptumRx||OptumRx (no change)|
|Specialty Pharmacy||CVS Specialty||Optum Specialty|
|Prescription Drug Program (formularies, UM decision criteria, appeals)||Point32Health||Point32Health (no change)|
|Utilization Management Determinations (Pharmacy Drugs)||OptumRx||Point32Health|
|Utilization Management Determinations (Medical Drugs)||CVS Health – NovoLogix||Point32Health|
|Infertility Pharmacy Program||Freedom Drug, Inc and Village Pharmacy||Optum Specialty|
Will Point32Health continue to develop and manage the drug formularies?
Yes, Point32Health will continue to develop and manage the prescription drug formularies.
When will the new formularies be available?
The 2023 prescription drug formularies will take effect on Jan. 1, 2023 and will be posted to our legacy organizations’ respective provider websites in Nov. 2022. We will strive to minimize any disruption for members.
Who will be responsible for pharmacy utilization management and appeals?
Point32Health will be responsible for developing the pharmacy medical necessity guidelines, as well as conducting prior authorization reviews and managing appeals.
What is the benefit of having Point32Health conduct pharmacy utilization management?
This enables us to deliver a more seamless provider experience by having a single point of contact to support providers with most medical and pharmacy benefit requests. There are a few exceptions: CareLink will continue to utilize Cigna; HPI will continue to conduct its own utilization management; and Harvard Pilgrim Health Care will continue to leverage the oncology and radiation oncology medical management program administered by OncoHealth.
Will the pharmacy medical necessity guidelines be consistent between the legacy brands?
For greater simplicity and an improved member and provider experience, Point32Health is unifying our pharmacy medical necessity guidelines within product lines. For example, the same pharmacy medical necessity guidelines will apply for Commercial Harvard Pilgrim Health Care and Commercial Tufts Health Plan members. Guidelines may vary across product lines, however (for example, Commercial and Public Plans policies may differ).
How will you support continuity of care for migrating members?
To ensure our members have uninterrupted access to their medication and reduce your administrative burden, we will do the following:
- Authorizations: We will transfer all active prior authorizations. These will remain valid for the length of the approval. There is no need to request a new authorization if previously obtained. Please keep in mind, however, that you should continue to notify the Plan of any changes to the authorization as you would today, in accordance with our authorization policies.
- Retail pharmacy prescriptions: Retail pharmacy prescriptions will remain active, and providers will not need to issue new prescriptions for members.
- Mail order: For Tufts Health Plan members who currently receive mail order drugs through CVS mail order, we will transfer prescriptions with available refills automatically to OptumRx home delivery prior to Jan. 1. On Jan. 1, members will be able to access the OptumRx portal to set up a new account and enter payment information. There are no mail order changes for Harvard Pilgrim Health Care members.
- Specialty refills: We will transfer any specialty refills over to OptumRx.
How should providers request authorization for pharmacy medications?
We have developed a new electronic tool, PromptPA, to enable quick, easy submission of prior authorization requests for both pharmacy benefit and medical benefit drugs. Beginning on Jan. 1, you will be able to access PromptPA through our provider portals (Harvard Pilgrim Health Care. and Tufts Health Plan) or directly through a dedicated website. Online submission enables you to easily view medical necessity guidelines, attach clinical information, check the status of your request, and receive a response more quickly. We also encourage the use of electronic prior authorization (ePA) through EMR, CoverMyMeds, or Surescripts.
Alternatively, you can submit prior authorization requests via FAX using the corresponding request forms. Updated forms — with new fax numbers — will be available in the pharmacy sections of our provider websites by to Jan. 1.
How can I learn more about PromptPA?
We’ll be sharing more information about PromptPA in the coming months, and information on the tool will be incorporated into our provider education sessions. We think you’ll find that the tool is easy to use, but we’ll also offer webinars and user guides to help you get started.
Who will be conducting utilization management for medical drugs?
Point32Health will develop the medical necessity guidelines for medical benefit drugs and will conduct utilization review, effective Jan. 1, 2023. Currently, CVS Health-Novologix conducts utilization management for medical drugs for Harvard Pilgrim Health Care members; however, as of Jan. 1, 2023, CVS Health-Novologix will no longer accept medical drug authorization requests for these members.
As noted above, Point32Health will have a team dedicated to conducting utilization management for drugs associated with the pharmacy and medical benefits. By having this single point of contact for both legacy brands, we hope to reduce your administrative burden and improve your experience in doing business with us.
When will the new medical drug guidelines be available?
We will be posting the medical necessity guidelines for medical benefit drugs on our provider websites by Nov. 1, 2022. You’ll find these policies on a dedicated Medical Drug Medical Necessity Guidelines webpage on the Harvard Pilgrim Health Care provider website and in the Resource Center for Tufts Health Plan.
Do you anticipate changes in the number of medical drugs that require prior authorization?
As we bring our medical benefit drug policies into alignment within lines of business, we anticipate the changes noted below. As a whole, the medical drugs requiring prior authorization will largely remain the same — and in some cases, authorization will no longer be required.
- Harvard Pilgrim Health Care Commercial: Prior authorization will no longer be required for IVIG/SCIG drugs for members under age 18; for non-oncology uses of 13 medical drugs; and for approximately 35 other drugs for various reasons (i.e., improving access, low risk of misuse). For the OncoHealth program that currently applies for Harvard Pilgrim Health Care Commercial members, Point32Health is removing prior authorization from 3 medical drugs. Prior authorization will be added for 3 medical benefit drugs.
- Tufts Health Plan Commercial & Direct: Prior authorization will be added for 13 medical drugs. The administration codes for botulinum toxin (Botox, Myobloc, Dysport, and Xeomin) will no longer require prior authorization.
- Tufts Health Public Plans: The administration codes for botulinum toxin (Botox, Myobloc, Dysport, and Xeomin) will no longer require prior authorization. Prior authorization will be newly required for 4 medical drugs for Tufts Health RITogether.
- Tufts Health Plan Medicare Plans: Prior authorization will be newly required for 7 medical drugs and will be removed from 2 medical drugs.
- Harvard Pilgrim StrideSM (HMO) Medicare Advantage: Prior authorization will be removed from 19 drugs when used for non-oncology purposes and 2 medical drugs for all purposes. Prior authorization will be newly required for 85 medical drugs. For complete information, refer to the medical necessity guidelines for medical drugs that will be available on our provider websites by Nov. 1.
How are dose/frequency limits applied?
To ensure the safe and appropriate use of medications, Point32Health applies industry standard maximum dosage and frequency guidelines to medications covered under the medical benefit in accordance with FDA-approved labeling, recognized compendia uses, and evidence-based guidelines. Dose and frequency limits are applied during claims processing; when receiving prior authorization for a medical benefit drug, the authorization will not note the dose/frequency limitation.
How should providers request authorization for medical benefit drugs?
As noted above, we have developed a new electronic tool, PromptPA, to enable quick, easy submission of prior authorization requests for drugs associated with both the pharmacy and medical benefits. Beginning on Jan. 1, you will be able to access PromptPA through our respective legacy Harvard Pilgrim Health Care and Tufts Health Plan provider portals or directly through a dedicated website. Online submission enables you to easily view medical necessity guidelines, attach clinical information, check status, and receive a response more quickly. We also encourage the use of electronic prior authorization (ePA) through EMR, CoverMyMeds, or Surescripts. Alternatively, you can submit prior authorization requests via FAX using corresponding request forms. Updated forms — with new fax numbers — will be available in the pharmacy sections of our provider websites by to Jan. 1, 2023.
Will existing authorizations for medical benefit drugs be carried over?
Yes, any approved authorizations for medical benefit drugs will remain active through the end date of the authorization. For existing Harvard Pilgrim Health Care Commercial members this means that any authorizations that were reviewed and approved by CVS Health-Novologix will be uploaded into Harvard Pilgrim Health Care’s systems and will be honored. For members moving from Tufts Health Plan Commercial plans to Harvard Pilgrim Health Care Commercial plans, any open medical drug benefit authorizations will also continue to be valid through the end date identified on the authorization. If you have questions about the transfer of a medical drug authorization for a member who is being moved from a Tufts Health Plan Commercial product to a Harvard Pilgrim Health Care Commercial product, you may call the Harvard Pilgrim Health Care Provider Service Center at 800-708-4414 (option 1, then option 7).
Are you aligning your medical necessity guidelines?
Throughout this year, we have been reviewing and assessing medical necessity guidelines for each legacy organization with the intent to align them for greater ease and efficiency. The majority of our guidelines have undergone review, and in cases where significant updates were made, we announced those changes via our monthly provider newsletters. We will have completed review of all remaining guidelines by January 2023 and will continue to provide notice of substantive changes in our provider newsletters.
Will existing authorizations be honored for Commercial members transitioning from Tufts Health Plan to Harvard Pilgrim Health Care?
Yes, as part of our commitment to facilitating a seamless transition for members and providers, any existing authorizations for medical and behavioral health services will be valid. This means that providers will not have to submit a duplicate authorization request for the same services/time period for migrating members. The existing authorization will be valid through the expiration date.
How can I be certain an existing medical service authorization was transitioned for a Commercial migrating member?
If you have questions about the transfer of a medical authorization for migrating Commercial members, you may call the Provider Service Center at 800-708-4414 (option 1, then option 7).
Will existing referrals also be honored for Commercial migrating members?
We will honor active, open referrals for members migrating from a Tufts Health Plan Commercial plan to a Harvard Pilgrim Health Care Commercial plan.
What will happen if a Commercial migrating member is currently receiving care management services with Tufts Health Plan?
Care management services are vital to improving patient care by enhancing coordination of care, eliminating duplication, and aiding patients and caregivers in more effectively managing their health conditions. We will transfer medical care management cases from Tufts Health Plan’s care management team to Harvard Pilgrim Health Care’s care management team and will ensure that the member continues to receive care management services.
For behavioral health services, if a migrating member is working with a Tufts Health Plan behavioral health care manager, from dates of service between Jan. 1 – July 1, 2023, the case will be transitioned to Optum, which currently provides behavioral health services for Harvard Pilgrim Health Care members. Beginning July 1, 2023, Harvard Pilgrim Health Care will provide behavioral health care management services directly.
What will happen if a Commercial migrating member is at an inpatient facility at the time of their plan change?
For patients receiving inpatient care at the time of their plan migration, medical care management services will continue to be provided by the Tufts Health Plan care management team. Upon discharge, the case will be transferred to the appropriate care management team: Harvard Pilgrim Health Care’s team for medical care management and Optum for behavioral health care management (until the time of Harvard Pilgrim Health Care’s behavioral health insourcing in July 2023).
What will happen if a commercial migrating member is receiving care from a provider who is not in the Harvard Pilgrim Health Care network?
We are committed to ensuring as little disruption for members and providers as possible. Given the robustness of our networks and similarities in composition, we anticipate that the vast majority of members will be able to continue to see their providers without interruption. In the event that a migrating member is currently in active care with a provider who isn’t in the Harvard Pilgrim Health Care network for their new product, the member can utilize Harvard Pilgrim Health Care’s standard Continuity of Care policy for between 90-180 days depending on the date of the member’s migration. For more information, please refer to the Continuity of Care/Transitional Care Request Form.
Are there any changes to vendor medical management programs?
For Harvard Pilgrim Health Care, medical benefit drug management will be managed in-house, rather than by CVS Health-Novologix, beginning on Jan. 1, 2023. The programs managed in partnership with AIM Specialty Health, National Imaging Associates (NIA), OncoHealth, Progeny Health and EviCore will remain in place. While Tufts Health Plan must receive authorization from EviCore for sleep studies, Harvard Pilgrim Health Care members must receive authorization for sleep studies from NIA; thus, once a member moves from a Tufts Health Plan Commercial product to Harvard Pilgrim Health Care Commercial product, the providers would request new authorizations for sleep studies from NIA. For information on vendor programs, please refer to the Harvard Pilgrim Health Care Vendor Program page and Tufts Health Plan Vendor Information page on the legacy organizations’ provider websites.
What changes are anticipated for behavioral health?
Behavioral health care plays an essential role in the overall health and wellbeing of individuals, and we’re focused on ensuring that our members have access to the highest quality behavioral health care. Point32Health will offer an insourced behavioral health program – meaning that rather than outsourcing behavioral health to a separate vendor (sometimes called a “carve-out” model), we will contract directly with behavioral health providers and our organization will manage both medical and behavioral health care coverage and programs, including utilization and care management.
Is that a change for the legacy organizations?
While Tufts Health Plan currently operates using an insourced behavioral health model, this is a change for Harvard Pilgrim Health Care, which currently utilizes a carve-out model managed by Optum/United Behavioral Health.
When will behavioral health services be insourced for Harvard Pilgrim Health Care?
Harvard Pilgrim Health Care will utilize an insourced behavioral health program effective July 1, 2023.
What are the benefits of an integrated, insourced behavioral health model?
This model will offer members and providers a more seamless experience, with a single point of contract across both legacy organizations. This model also:
- Utilizes a whole-health network of both medical and behavioral providers
- Emphasizes highly coordinated care management and outreach that connects behavioral health and physical health
- Yields more comprehensive analytics (single data set for medical and behavioral health) that enable Point32Health and provider organizations to see members through a holistic lens and identify opportunities for improved care and patient experience
Will existing Tufts Health Plan behavioral health providers be available to Harvard Pilgrim Health Care members?
We are amending our contracts with Tufts Health Plan behavioral health providers to enable them to provide care to Harvard Pilgrim Health Care members. Contract amendments are being sent to providers in a phased approach with the first group of contract amendments being sent in August. We are also recruiting behavioral health providers who are not currently in the Tufts Health Plan network to join the network for all our Point32Health members.
How will you ensure continuity of care in the January-July timeframe when some members transition from a Tufts Health Plan Commercial product to a Harvard Pilgrim Health Plan product?
Our network analyses have found that most Tufts Health Plan contracted behavioral health providers also participate in the Optum network that currently provides behavioral health care to Harvard Pilgrim Health Care members. In cases where the behavioral health provider is not in the Optum network, Point32Health will make accommodations to ensure that the member can continue to see their behavioral health provider through the transition period. We will be providing more detail on this in future provider newsletter articles and FAQ updates.
I am a behavioral health provider who received a contract amendment and have questions. Who should I contact?
Please contact the Ancillary Behavioral Health Contracting team by email at AHCBehavioralHealth@point32health.org or by phone at 617-972-9400 x 43145.
What electronic tools can I access for my patients moving to Harvard Pilgrim Health Care Commercial products?
HPHConnect, Harvard Pilgrim Health Care’s web-based transaction service, is free, HIPAA-compliant, and available 24/7. If you are a participating Harvard Pilgrim Health Care provider and aren’t currently registered, we encourage you to register today. HPHConnect allows you to perform a host of transactions quickly and easily, including submitting claim batch files, verifying patient eligibility, checking claim status, sending and receiving specialty referrals and authorization, provider notification, and viewing a patient’s personal health record. You can also access reports and tools such as drug formularies and pharmacy program information, PCP membership reports, claims reports, and more.
Visit the Electronic Tools and HPHConnect page on the Harvard Pilgrim Health Care provider website for more details on HPHConnect and sending electronic transactions.
For your patients remaining on Tufts Health Plan products, you should continue to utilize the Tufts Health Plan electronic tools, including the Tufts Health Plan secure provider portal and self-service tools.
How do I sign up for electronic payment?
If you’re receiving paper checks, we encourage you to make the simple switch to electronic funds transfer through Payspan today. For information on receiving EFT from Harvard Pilgrim Health Care, visit the visit the Electronic Payment tab of our Electronic Tools and HPHConnect page. To receive EFT from Tufts Health Plan, select the EFT tab on the Electronic Services webpage.
Can I provide care for Tufts Health Plan/Harvard Pilgrim Health Care members even though I’m not in their network?
Providers must be contracted with the applicable network. To leave more about joining our networks, please visit:
I’m a behavioral health provider and would like to join the Harvard Pilgrim Health Care network. How can I do so?
We’re pleased that you are interested in joining the network; we’re committed to providing exceptional behavioral health services to all Point32Health members and are focused on whole-person care, so it is invaluable to us to maintain a robust network of providers like you. For information on joining the Harvard Pilgrim Health Care behavioral health network, effective for dates of service of July 1, 2023 and beyond, please contact the Ancillary Behavioral Health Contracting team by email at AHCBehavioralHealth@point32health.org or by phone at 617-972-9400 x 43145.
Will you be offering training sessions on these topics?
We want to make it as easy as possible for you and your office staff to do business with us, and one step we’re taking in support of this goal is offering educational webinar sessions — and online resources and tools — so you have access to the information you need. We’ll announce training opportunities in our monthly provider newsletters. We also encourage you to visit the Harvard Pilgrim Health Care Provider Training and Events page page and the Tufts Health Plan Provider Training page.
How can I sign up for the monthly provider newsletter?
Our provider newsletters will keep you up to date on important changes. We encourage providers and office staff to sign up for monthly email delivery:
Tufts Health Plan: See the latest newsletter issue here. Register for email delivery.
Where can I access Provider Manuals?
Our Provider Manuals offer up-to-date guidance on Harvard Pilgrim products, programs, policies, and procedures: