CommercialPrior AuthHigh impact
Point32Health Medical Necessity Guideline updates
Harvard Pilgrim Health Care·Prior Authorization
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
Point32Health updated multiple Medical Necessity Guidelines with mixed prior authorization changes: new requirements through Carelon for Harvard Pilgrim Commercial starting March 1, 2026, while removing prior auth for several services including manual wheelchairs, oxygen equipment, and home health visits effective January 1, 2026.
Action Required
By January 1, 2026: Remove prior authorization requirements from billing system for CPT 99501 (home health visits), manual wheelchairs, and oxygen/respiratory equipment for applicable Point32Health plans. By March 1, 2026: Implement new prior authorization requirements for Carelon medical benefits management program codes for Harvard Pilgrim Commercial - refer to Point32Health provider website for complete code list. Update FMT billing to ensure codes G0455 and 44705 are only billed with diagnosis codes A04.71 or A04.72 for Uniformed Services Family Health Plan members.