CommercialCoverageHigh impact
New laboratory Payment Policies
Harvard Pilgrim Health Care·Family Medicine, Internal Medicine, General Practice +14 more·Reimbursement
Effective date
Nov 1, 2025
We identified it
Jun 26, 2026
Summary
Harvard Pilgrim Health Care is implementing a new laboratory benefit management program with automated claims edits for 60+ specific lab tests and procedures effective November 1, 2025. These evidence-based policies will apply to office, hospital outpatient, and independent laboratory settings (excluding ER, observation, and inpatient). Billing teams must review detailed payment policies on the provider website and adjust ordering/requisition forms to ensure compliance and avoid claim denials.
Action Required
By October 15, 2025: (1) Billing team and providers must access the Harvard Pilgrim Payment Policy section at https://www.point32health.org/provider/new-laboratory-payment-policies-092025 and review all 60+ laboratory policies prefixed with 'Laboratory:' (e.g., 'Laboratory: Colorectal Cancer Screening', 'Laboratory: Hepatitis C'). (2) Providers and laboratories using requisition forms and panels must update forms and standing orders to align with new payment policies. (3) Billing team must configure automated claim edits in billing software to match Harvard Pilgrim's post-service, pre-payment edits to prevent submission of non-covered tests. (4) Document any lab tests currently ordered that appear on the new policy list and verify medical necessity guidelines. (5) Train front-desk and clinical staff on policy changes. Consequence: Claims for laboratory services that do not meet new payment policy criteria will be denied post-service. NOTE: Maine providers are excluded from the November 1 effective date; separate guidance will be provided in the October provider newsletter.