NETWORK MATTERS COVID-19 Updates for Providers Harvard Pilgrim Health Care is making the following updates to our COVID-19 policies
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NETWORK MATTERS August 2021 COVID-19 Updates for Providers Harvard Pilgrim Health Care is making the following updates to our COVID-19 policies: Cost Sharing Update for Z03.818 Please note that Harvard Pilgrim Health Care will apply appropriate member cost-sharing for outpatient and observation claims billed with code Z03.818 (Encounter for observation for suspected exposure to other biological agents ruled out). For members of our Massachusetts commercial plans, this change is effective for dates of service beginning Sept. 30, 2021. For Medicare Advantage members in all states and for commercial members in Maine, New Hampshire and Connecticut, this change is effective for dates of service on or after Aug. 7, 2021, as part of the resumption of cost sharing for COVID-19 treatment for these markets and products, which was announced in the June issue of Network Matters. COVID-19 Vaccination at Home For our commercial members in all states, Harvard Pilgrim will reimburse for code M0201, which became effective June 8, 2021 and provides additional reimbursement for vaccine administration in the home setting. For more information Our COVID-19 page for providers and our COVID-19 coding grid have been updated to reflect these changes. We encourage you to visit these regularly for the most up-to-date information on Harvard Pilgrim’s COVID-19 coverage, policies and procedures. Reminder: Whole Genome Sequencing Program Managed by AIM As a reminder, Harvard Pilgrim covers whole genome sequencing (WGS) in the outpatient setting for pediatric commercial members who meet the appropriate criteria — and medical review is performed by our genetic testing authorization vendor, AIM Specialty Health. WGS is a comprehensive method for analyzing entire genomes. Delivering a large volume of data in a short time, WGS is able to identify large and small variants that might be missed with targeted approaches — allowing for quicker detection and diagnosis of genetic conditions in children with complex cases. An innovative partnership Harvard Pilgrim is pleased to be working with AIM and Illumina, Inc., a global leader in DNA sequencing and array-based technologies, to offer WGS.
NETWORK MATTERS August 2021 “Harvard Pilgrim proudly continues to lead the way in agreements designed to promote access for our members to leading-edge precision medicine technology, while containing costs for consumers and employers,” said Michael Sherman, MD., Harvard Pilgrim’s Chief Medical Officer. “Our members will be able to take advantage of this comprehensive technology, potentially saving themselves enormous frustration, heartache, and financial challenges. Moreover, Illumina gains the opportunity to demonstrate its value in a real-world setting through expanded use of WGS, while Harvard Pilgrim provides additional benefits but deters additional expenses that would otherwise increase costs for our members.” For more information, please refer to the press release on this partnership. Requesting WGS Genetic counseling is required, and WGS must be requested by an independent medical geneticist, genetic counselor, or genetic nurse. In addition, testing must be performed at one of Harvard Pilgrim’s in-network laboratories; please refer to the online Provider Directory for information on participating laboratories. Authorization for WGS should be requested through AIM either online through HPHConnect’s single sign on feature, via the AIM portal directly, or by telephone at 855-574-6476. For more details, please refer to the prior authorization criteria on AIM’s website. Aducanumab (Aduhelm) is Considered Experimental and Investigational After reviewing the clinical data that is available on the efficacy and safety of the Alzheimer’s drug aducanumab (Aduhelm), Harvard Pilgrim Health Care has concluded that it is experimental and investigational. In making this clinical determination, we consulted with our internal resources, as well as our regional providers who offer extensive expertise in this area. This decision was made with our members’ health and well-being in mind and was not based on cost. Our priority is to provide our members with coverage for effective and safe treatments that are based on scientific evidence. Alzheimer’s disease is very personal to many of us at Harvard Pilgrim Health Care, and the need for an effective new treatment for Alzheimer’s is indisputable. We are encouraged that there is a robust pipeline of other Alzheimer’s drugs in current research and development. As further studies and data related to aducanumab become available, we will carefully review the information and continue to evaluate this clinical decision.
NETWORK MATTERS August 2021
While our clinical evaluation of this drug therapy is universal, for our Medicare and Medicaid
lines of business we will continue to follow the direction of our federal and state regulators
regarding coverage.
Prior Authorizations for Medical Drugs
Effective for dates of service beginning Oct. 1, 2021 for members of our commercial plans,
Harvard Pilgrim will require prior authorization for the following medications:
• Ultomiris (HCPCS code J1303: Injection, ravulizumab-cwvz, 10 mg)
• Fibryga (HCPCS code J7177: Injection, human fibrinogen concentrate [Fibryga], 1 mg)
• Hemophilia products (HCPCS codes J7178, J7212, J7181, J7180): Factor
VIII, Obizur, Factor IX, Factor IX Complex, FEIBA, Novoseven
RT, Sevenfact, Hemlibra, Coagadex, Corifact, Tretten, Vonvendi, Vonvendi, RiaSTAP
• Kcentra (HCPCS code J7168: Prothrombin complex concentrate [human], kcentra, per
I.U. of factor IX activity)
To request authorization, please contact CVS Health–NovoLogix via phone (844-387-1435) or
fax (844-851-0882).
For complete information, including coverage criteria and FDA-approved maximum dosage and
frequency limits, please refer to the applicable policies.
No Prior Authorization for Bunionectomy Procedures
Harvard Pilgrim would like to inform our provider network that for dates of service beginning
Aug. 1, 2021, prior authorization is no longer required for our commercial members for
coverage of bunionectomy procedures for hallux vagus designated by the following CPT codes:
• 28289 – Hallux rigidus correction with cheliotomy, debridment, and capsular release of
the first metatarsophalangeal joint; without implant
• 28291 – Hallux rigidus correction with cheilectomy, debridement and capsular release of
the first metatarsophalangeal joint; with implant
• 28292 – Correction, hallux valgus (bunion), with or without sesamoidectomy; Keller,
McBride or Mayo type procedureNETWORK MATTERS August 2021
• 28295 – Correction, hallux valgus (bunionectomy), with sesamoidectomy, when
performed; with proximal metatarsal osteotomy, any method
• 28296 – Correction, hallux valgus (bunionectomy), with sesamoidectomy, when
performed; with distal metatarsal osteotomy, any method
• 28297 – Correction, hallux valgus (bunionectomy), with sesamoidectomy, when
performed; with first metatarsal and medial cuneiform joint arthrodesis, any method
• 28298 – Correction, hallux valgus (bunionectomy), with sesamoidectomy, when
performed; with proximal phalanx osteotomy, any method
• 28299 – Correction, hallux valgus (bunionectomy), with sesamoidectomy, when
performed; with double osteotomy, any method
• 28306 – Osteotomy, with or without lengthening, shortening or angular correction,
metatarsal; first metatarsal
• 28310 – Osteotomy, shortening, angular or rotational correction; proximal phalanx, first
toe (separate procedure)
• 28750 – Arthrodesis, great toe, metatarsophalangeal joint
As prior authorization is no longer required for this procedure, the commercial Bunionectomy
Medical Policy has been archived as of Aug. 1.
Medical Policy for New-to-Market Medications
Harvard Pilgrim has developed a policy for the commercial review of new-to-market
medications under the medical benefit. The policy outlines the criteria that must be met and
documented in order for these medications to be considered reasonable and medically
necessary, as well as exclusions that should be noted.
For complete information, please refer to Harvard Pilgrim’s New-to-Market Medications Under
Medical Benefit Medical Policy.
Updates Regarding Oncology Drugs
The drugs Jemperli and Rybrevant (both of which use HCPCS code J9999 – not otherwise
classified, antineoplastic drugs) will now require prior authorization through Oncology AnalyticsNETWORK MATTERS August 2021
when used for oncology purposes for members of Harvard Pilgrim’s commercial and
StrideSM (HMO) Medicare Advantage plans.
Oncology Analytics conducts medical review of chemotherapeutic protocols (chemotherapy,
support and symptom management drugs) and radiation treatment plans for Harvard Pilgrim
members with a cancer diagnosis that requires these services.
You can view prior authorization criteria for oncology drugs, as well as any recent coding
updates, on the Oncology Analytics website. To request authorization, contact Oncology
Analytics by fax (800-264-6128), phone (877-222-2021), or online via HPHConnect.
Harvard Pilgrim’s Access to Care Standards
One of Harvard Pilgrim’s fundamental priorities is ensuring the best possible access to care for
the members we serve. To that end, Harvard Pilgrim maintains commercial and StrideSM (HMO)
Medicare Advantage policies that outline network practitioner standards regarding clinician
availability, timeliness of appointments, and telephone accessibility, among other things.
Commercial Practice Site Standards Policy
The Practice Site Standards highlights specific standards in a variety of areas from telephone
accessibility to standards for the office, waiting room, and exam rooms. Access to care
guidelines include, but are not limited to:
• In general, PCPs should not keep members with a scheduled appointment waiting an
unreasonable length of time
• Acceptable telephone coverage available after primary care office hours and reasonable
time between pick up and connection
• Emergency coverage available on a 24-hour basis for all covered services
• Urgent appointments within 24 hours
• Non-urgent appointment timeframes vary with state guidelines for MA, ME, and NH.
Typically, PCPs’ symptomatic or medically necessary office visits should be available
within 7 days.
• For specialty adult and pediatric providers, initial non-urgent visits should be available
within 14 days and urgent visits for most states within 7 days (24 hours for ME)
Medicare Advantage Access to Care Standards
Likewise, the Medicare Advantage Access To Care policy outlines standards and requirements
for Harvard Pilgrim network providers regarding accessibility and timeliness of care provided.
The Centers for Medicare and Medicaid Services (CMS) requires that practitioners maintain
convenient hours of operation and non-discriminatory access to services. To that end, the
policy indicates that practitioners must provide coverage for their practice 24 hours a day,NETWORK MATTERS August 2021
seven days a week with a published after-hours telephone number, pager or answering service,
or a recorded message directing members to a provider for after-hours care instruction.
Other access to care requirements include, but are not limited to:
• Preventive care appointment or immunization: within 90 days of a member’s request
• Scheduled appointments: within 30 minutes of member’s arrival
• Routine/well care appointment: within one month of a member’s request
• Urgent appointment: within 48 hours of a member’s request
• Telephone responsiveness: Providers should give a timely response to incoming phone
calls. Providers should answer calls in six rings or less and limit hold time to two minutes
or less.
In addition, all services must be accessible to all members — including those with limited
English proficiency or reading skills and those with diverse cultural and ethnic backgrounds —
and provided in a culturally competent manner. For complete information, please refer to our
commercial Practice Site Standards and Medicare Advantage Access To Care policies.
Members’ Rights and Responsibilities
Harvard Pilgrim members receive a copy of the Members’ Rights and Responsibilities upon
enrollment, and all clinicians receive a copy at the time of contracting and credentialing and
annually thereafter. Periodically, Harvard Pilgrim includes this information in Network Matters.
Please take a moment to review. Because this information may vary among states, please be
sure to read the full Rights and Responsibilities page of the commercial Provider Manual.
Members have a right to:
• Receive information about Harvard Pilgrim, its services, its practitioners, and providers,
and members’ rights and responsibilities
• Be treated with respect and recognition of their dignity and right to privacy
• Participate with practitioners in decision-making regarding their health care
• Engage in a candid discussion of appropriate or medically necessary treatment options
for their conditions, regardless of cost or benefit coverageNETWORK MATTERS August 2021
• Voice complaints or appeals about Harvard Pilgrim or the care provided
• Make recommendations regarding the organization’s members’ rights and
responsibilities policy
Members have a responsibility to:
• Provide, to the extent possible, information that Harvard Pilgrim and its practitioners
and providers need to care for them
• Follow the plans and instructions for care that they have agreed upon with their
practitioners
• Understand their health problems and participate in developing mutually agreed-upon
treatment goals to the degree possible
Edits to Cardiology & Cardiovascular Surgery Payment Policy
Harvard Pilgrim is updating our commercial Cardiology & Cardiovascular Surgery Payment
Policy and will apply a number of additional coding edits, effective for dates of service
beginning Oct. 1, 2021.
Edits to the policy will include:
• Cardiac catheterization will deny when billed with a percutaneous coronary procedure
and another cardiac catheterization has been billed in the previous week by any
provider, as the information gathered from the second catheterization is duplicative of
the first catheterization.
• External mobile cardiovascular telemetry or external patient activated ECG event
recording will deny when billed more than once in a six-month period by any provider.
• Programming/interrogation device evaluation (in person) defibrillator system will deny
when billed more than once in a three-month period for a diagnosis indicating the
presence of an automatic (implantable) cardiac defibrillator.
• A routine electrocardiogram will deny when billed in the office setting for a patient 18
years of age or older and the only diagnosis is a screening diagnosis code. According toNETWORK MATTERS August 2021
the U.S. Preventive Services Task Force, it is not appropriate to screen for coronary
disease in asymptomatic adult patients.
• A complete transthoracic echocardiography will deny when the same complete
echocardiography has been billed within six months with the same diagnosis. The
second study should represent a follow-up study given the fact that the complete study
has already been done recently for the same condition.
• A duplex scan of extracranial arteries (study) will deny when billed in the office setting
and the patient is 18 years of age or older and a carotid artery stenosis symptom
diagnosis is not present. According to the U.S. Preventive Services Task Force, it is not
appropriate to screen for carotid artery disease in asymptomatic adult patients.
• A stress test will deny if billed within six months of another stress test when an
echocardiography/cardiac nuclear imaging procedure has not occurred on the same
date of service, or if a coronary intervention has not occurred within that time frame. In
addition, a plain stress test will deny for exceeding clinical guidelines if a previous plain
stress test has been billed in the last 180 days with the same diagnosis and a cardiac
intervention has not also occurred in the previous 180 days.
• A stress test and echocardiography/cardiac nuclear imaging procedure will deny when it
is billed on the same date and within six months of another echocardiography/cardiac
nuclear imaging procedure, and a coronary intervention has not also been billed on the
same date of service or within the previous six months. A physician should only bill a
non-complex or complex stress test once within a six-month period unless there is a
significant change in the patient’s condition.
• Cardiac stress tests or stress echocardiograph testing for a patient 18 years of age or
older will deny when the only diagnosis on the claim is for a general routine exam or a
screening for cardiovascular disorders.
For more information, please refer to the Cardiology & Cardiovascular Surgery Payment Policy.
NETWORK MATTERS August 2021
Network Matters is a monthly newsletter for the Harvard Pilgrim provider network
Annmarie Dadoly, Editor
Joseph O’Riordan, Writer
Kristin Edmonston, Production Coordinator
Read Network Matters online at www.hphc.org/providers. For questions or comments about
Network Matters, contact Annmarie Dadoly at annmarie_dadoly@harvardpilgrim.org or (617)
509-8074.You can also read
