CommercialCoverageHigh impact
Billing updates effective Nov. 1, 2026
Harvard Pilgrim Health Care·OB-GYN, Radiology·Reimbursement
Effective date
Nov 1, 2026
We identified it
Sep 5, 2026
Summary
Effective Nov. 1, 2026, Tufts Health Direct will deny reimbursement for CPT code 99459 (pelvic exam add-on) and CPT codes 76376 and 76377 (3D rendering with interpretation) when billed, as these services are now considered integral to primary procedure codes. Modifier usage will not override these denials.
Action Required
By October 31, 2026: Billing team must update billing system to automatically deny or flag claims containing CPT codes 99459, 76376, and 76377 for Tufts Health Direct members with dates of service on or after November 1, 2026. Remove these codes from billing templates and encounter forms used by OB/GYN and imaging service providers. Communicate to clinical staff that pelvic exam expenses are now bundled into primary E/M visit codes and 3D rendering is bundled into primary imaging codes. Establish process to identify and rework any claims submitted with these codes to avoid denials. Update billing guidelines and staff training materials to reflect bundled reimbursement model.