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Applied behavioral analysis policy and coverage updates
Effective date
Jan 1, 2026
Identified
Jun 20, 2026
Summary
Point32Health is implementing comprehensive changes to Applied Behavioral Analysis (ABA) therapy policies effective January 1, 2026, including expanded Down syndrome coverage in Massachusetts, new InterQual criteria for prior authorizations, and coding changes that eliminate HCPCS codes H0031/H0032 for Harvard Pilgrim Commercial plans while requiring prior auth for CPT 0362T on Tufts Health Direct.
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What to do
Action · 3 steps
01Before January 1, 2026: Billing team must update system to stop billing HCPCS codes H0031 and H0032 for Harvard Pilgrim Commercial plans and require prior authorization for CPT 0362T on Tufts Health Direct plans.
02Update encounter forms and billing rules to reflect new Down syndrome coverage requirements for Massachusetts members.
03Ensure staff use correct prior authorization forms: state Standard Form for Harvard Pilgrim Commercial, Tufts Health Direct, and Tufts Health Plan Commercial members, or Point32Health's updated form for Tufts Health Together members.
Codes mentioned
H0031H0032
Original notice
Applied behavioral analysis policy and coverage updates
point32health.org · Always check the source before changing claims.