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Harvard Pilgrim Health CareCommercial · Prior Auth · Prior Authorization · Sleep Medicine, PulmonologyHigh impact

Upcoming sleep management program enhancements

Effective date
Dec 1, 2026
Identified
Oct 20, 2026

Summary

Effective December 1, 2026, Point32Health is consolidating sleep management program administration under EviCore for Harvard Pilgrim Commercial and Tufts Health RITogether members. This shifts sleep study prior authorization from Evolent to EviCore, replaces Harvard Pilgrim's notification-only PAP device process with mandatory prior authorization, and eliminates notification requirements for Tufts Medicare Preferred members. Home sleep tests will no longer require prior authorization or notification for Harvard Pilgrim Commercial members.

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What to do

Action · 7 steps
01Before December 1, 2026.
02Billing team must update internal workflows to route all sleep study, PAP device, and PAP supply/resupply prior authorization requests to EviCore (at EviCore.com or 888-511-0401) for Harvard Pilgrim Commercial and Tufts Health RITogether members, replacing current Evolent and internal routing.
03Configure billing system to remove prior authorization requirement for home sleep tests (HSAT) for Harvard Pilgrim Commercial members.
04Update PAP device and supply/resupply authorization processes to require objective compliance data via EviCore's TherapySupport program for medical necessity review.
05Ensure front-line staff and providers understand that EviCore will begin accepting prior authorization requests on November 16, 2026, for dates of service beginning December 1.
06Review updated Provider Manuals and vendor website resources (FAQ, Quick Reference Guide, CPT code list) on the EviCore Point32Health provider resource site.
07Attend or access recordings from scheduled EviCore training sessions (November 17, 19, 23 and December 3, 8, 10, 2026) to understand new program requirements and EviCore portal navigation.
If missed: Failure to transition to EviCore-managed prior authorization before December 1, 2026, will result in claim denials for sleep-related services.

Original notice

Upcoming sleep management program enhancements
point32health.org · Always check the source before changing claims.
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Harvard Pilgrim Health Care policiesSleep MedicinePulmonology

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