CommercialCoverageHigh impact
Reminder: Observation Stay Policy and dispute process
Harvard Pilgrim Health Care·Provider Newsletter
Effective date
Jan 1, 2025
We identified it
Jun 20, 2026
Summary
Point32Health (Harvard Pilgrim and Tufts Health Plan) implemented a new policy effective January 1, 2025, that automatically reviews all inpatient stays up to 48 hours to determine if they should be reclassified and paid as observation stays instead. The policy includes specific exceptions and a new expedited dispute process for incorrectly denied inpatient requests.
Action Required
Immediately: Billing team must review all Point32Health/Harvard Pilgrim/Tufts Health Plan inpatient admissions under 48 hours and expect administrative denials that require resubmission as observation stays. Update staff training on the six policy exceptions (behavioral health, obstetrical delivery, patient death/AMA discharge, neonatal, intensive critical care, and transfers within 48 hours). Create workflow for submitting expedited disputes to shortstayexceptions@point32health.org with required information (Member ID, date of service, specific exception reason, claim ID). Claims initially denied as inpatient will need resubmission as observation stays for proper reimbursement.