Point32Health Payment Policy updates

REQUIREMENTS: By August 15, 2026: Billing team must prepare for policy implementation on 9/1/2026: - Review updated policies in the Payment Policies section of the Point32Health provider website for all 18 affected policies (Maximum Units, Surgery, Limited Services Clinics, Outpatient Facility, Laboratory and Pathology, Chiropractic Services, Dialysis, and five laboratory-specific policies, plus specialty policies for Harvard Pilgrim Health Care Commercial) - Update internal billing guidance to reflect the new definition: 'once-yearly reimbursement' = reimbursement every 365 days (affects Laboratory and Pathology billing) - Reference the Inpatient Hospital Admissions Payment Policy for interim billing information (Interim Billing policy for HPHC Commercial is now archived) By October 15, 2026: Billing team must configure system changes for 11/1/2026 effective date: - Update billing system to deny CPT code 99459 when billed for Tufts Health Direct members (Obstetrics/Gynecology service) - Update billing system to deny CPT codes 76376 and 76377 when billed for Tufts Health Direct members (Imaging services) - Configure system edits to auto-deny claims with these codes for Tufts Health Direct and route to providers with explanation of denied codes - Staff should review the referenced detailed explanations on the Point32Health website to understand the clinical rationale FAILURE TO IMPLEMENT: Claims for CPT 99459, 76376, and 76377 submitted to Tufts Health Direct on or after 11/1/2026 will be denied. Administrative updates affecting billing accuracy (365-day recalculation) may result in incorrect reimbursement calculations if not implemented.