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NETWORK MATTERS May 2021 New Training and Events Page Features Helpful Videos Harvard Pilgrim is thrilled to introduce you to the newest undertaking in our ongoing initiative to deliver the best possible experience for our network providers and office staff: the Provider Training and Events page on our provider website. We strive to be a health plan that’s easy for you to do business with, and this new page aims to further that goal by providing you with information about upcoming provider events, recordings of recent provider meetings and events in case you weren’t able to attend live, and a collection of helpful new training videos. Training videos with you in mind Don’t miss out on these short training videos designed to make common transactions a cinch Videos currently available offer step-by-step guidance on: • How to Register for HPHConnect • Checking Eligibility on HPHConnect • Checking Claims Status on HPHConnect And stay tuned, because we have more videos coming! We value your feedback As always, we love to hear feedback from our valued providers so we can continue to make improvements in our provider service and satisfaction efforts. The Provider Training and Events page offers you the opportunity to pass along any suggestions you may have for tools and training videos you would like to see developed. We hope to hear from you! Sign Up for Claims and Appeals Webinar As part of our continuing network engagement series, we’re offering virtual sessions on claims and appeals in June. Harvard Pilgrim invites you and your office staff to register for one of the event’s three available dates. Our April event was a resounding success. Thank you to all who attended. We received some excellent provider feedback, which we leveraged to determine the focus of the upcoming June sessions. At this network webinar, we’ll share best practices and helpful tips for claims and appeals. Sessions will be 60 minutes in total, including a Q&A session. To register, click the link corresponding to the date that works best for you and submit the requested information on the event registration page:
NETWORK MATTERS May 2021 • Wednesday, June 9 from 2–3 p.m. • Thursday, June 10 from noon–1 p.m. • Friday, June 18 from 9–10 a.m. We’ll be offering other provider meetings throughout the year, with these sessions focused on other specific topics. Look to future issues of the newsletter for details on upcoming sessions. For additional information on the provider engagement meetings, please contact your Provider Relations Consultant. COVID-19 Updates for Providers As a reminder, we encourage you to visit the COVID-19 page on our provider website to access resources designed to aid you in conducting operations during the pandemic, including any updates on COVID-19-related coverage, policies, and procedures; our COVID-19 coding grid; and our Interim Telemedicine and Telehealth Payment Policy. Please continue to let us know how we can support you by contacting the Provider Service Center at 800-708-4414 or your Provider Relations Consultant or Contract Manager as appropriate. Payment Policy Review and Integration As part of our integration work as a combined organization, we are reviewing and assessing existing Harvard Pilgrim Health Care and Tufts Health Plan Payment Policies, both as part of our typical annual review and to assess opportunities for consistency. We expect this work to continue over the course of the next year. The policies listed below are scheduled for review over the next few months. We’ll keep providers and office staff well informed of any changes and will continue to provide timely notice for any payment policy updates via Network Matters. Look to future issues of the newsletter for notifications on any payment policy updates. May • Allergy Testing and Treatment • Ambulance Transport • Cardiology & Cardiovascular Surgery • Gynecology • Human Leukocyte Antigen Testing
NETWORK MATTERS May 2021 • Nutritional Counseling • Radiology • Rehabilitation/Long-Term Acute Care Hospitals • Skilled Nursing Facility • Telemedicine/Telehealth June • Dermatology • Diabetic Care • Early Intervention • Emergency Care • Hospice Care • Inpatient Transfer Between Hospitals • Observation Stay • Podiatry July • Blood Products & Services • CPT & HCPCS Level II Modifiers • Drug Wastage • Interim Billing • Limited-Service Provider- Retail Medicine • Maximum Units Per Day • Orthopedic • Outpatient Surgery • Surgery To view our Payment Policies, please refer to the Provider Manual on our provider website. Virtual-First Product Coming to NH and ME Beginning on July 1, 2021, Harvard Pilgrim will offer the innovative virtually based network product SimplyVirtualSM HMO for employer groups in New Hampshire and Maine. SimplyVirtualSM HMO, which is currently offered in Connecticut, features a virtual-first care model and gives members 24/7 access to PCPs through virtual visits with our partner, Doctor On Demand.
NETWORK MATTERS May 2021
Members ages 19 and older select a PCP from Doctor On Demand’s network and access their
PCP through real-time video visits using the Doctor On Demand app or website. Virtual PCPs
refer members for any necessary office-based care, such as labs, x-rays, immunizations, and
specialist visits. Members under age 19 select from Harvard Pilgrim’s network of PCPs and
continue to receive office-based care. All specialists in Harvard Pilgrim’s network are considered
in-network for SimplyVirtualSM HMO members of all ages, and are eligible to render care with a
referral in accordance with existing Harvard Pilgrim referral policies.
You can recognize members with SimplyVirtualSM HMO by their ID cards; for further
information, refer to the Member Identification Cards policy in Harvard Pilgrim’s
online Provider Manual.
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 May 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.
InterQual Criteria: Electrical Bone Growth Stimulators
Effective for dates of service beginning July 1, 2021, Harvard Pilgrim will require prior
authorization for the use of bone growth stimulators for commercial members.
InterQual criteria will be used for commercial medical review for the following HCPCS codes:
• E0747 – Osteogenesis stimulator, electrical, noninvasive, other than spinal applications
• E0748 – Osteogenesis stimulator, electrical, noninvasive, spinal applications
• E0760 – Osteogenesis stimulator, low intensity ultrasound, noninvasive
We encourage providers and office staff to submit their authorization request through
HPHConnect, where an electronic authorization questionnaire will guide you through the
criteria. Using HPHConnect allows for a quicker response time — you can receive an on-the-
spot approval if you meet the criteria on the Smartsheet questionnaires.
For guidance on using HPHConnect to request an authorization and accessing the InterQual
criteria, refer to this training presentation. To request additional training, contact us
at Provider_Experience@harvardpilgrim.org. While Harvard Pilgrim encourages providers to
request authorization electronically, we will continue to accept authorization requests by
phone (800-708-4414) or fax (800-232-0816).NETWORK MATTERS May 2021
For more information, please refer to the Osteogenesis Stimulators Medical Policy. You may
view and print the applicable SmartSheet questionnaires via HPHConnect (go
to www.harvardpilgrim.org/providerportal, select Resources and then the Upcoming InterQual
link).
*Editor’s note: We have updated this article to reflect the name change of the medical policy.
Electrical Bone Growth Stimulators is now Osteogenesis Stimulators.
Prior Authorization for Lower Limb Protheses
Harvard Pilgrim maintains a commercial medical policy for prior authorization review of lower
limb prostheses and prosthesis equipment.
Harvard Pilgrim considers lower limb prostheses as reasonable and medically necessary when
prescribed by the attending physician (based on recommendations from a certified prosthetic
clinician) for individuals who:
• Have the potential to use the prosthesis for transfers and/or ambulation; and
• Can reasonably be expected to reach or maintain a predicted improved functional state
(with the use of the prescribed prosthesis) within a reasonable period of time; and
• Have adequate cardiovascular reserve and cognitive ability to effectively utilize the
device
For more information, including complete coverage criteria, coding, and exclusions, please refer
to the commercial Lower Limb Prostheses Medical Policy.
Medicare Advantage Reminder: Prior Authorization for Tysabri
As a reminder, Harvard Pilgrim requires prior authorization for all single agent Tysabri
(natalizumab) administered outside the inpatient setting for members of our StrideSM (HMO)
Medicare Advantage plans.
Harvard Pilgrim considers the use of Tysabri as reasonable and medically necessary for 12
months for relapsing forms of multiple sclerosis (MS) — including relapsing-remitting disease,
clinically isolated syndrome, and active secondary progressive disease — and for moderately to
severely active Crohn’s disease, when the criteria outlined on the StrideSM (HMO) Medicare
Advantage Tysabri Medical Policy policy are met.
Please note that per FDA labeling, before your patient can be covered for the use of Tysabri for
the treatment of MS or Crohn’s disease, supporting documentation must confirm that the
patient displays inadequate response to, or inability to tolerate, conventional MS/Crohn’s
disease therapies (and for Crohn’s, TNF-a inhibitors).NETWORK MATTERS May 2021 Refer to the policy for more information, including complete coverage criteria and exclusions. Epinephrine Coverage Reminders for Allergy Season With the spring allergy season upon us, Harvard Pilgrim would like to remind our provider network of our current coverage for epinephrine products within the commercial formularies (Premium, Value, Core NH). Epinephrine is indicated for the emergency treatment of allergic reactions including anaphylaxis to stinging insects and biting insects, allergen immunotherapy, foods, drugs, diagnostic testing substances, and other allergens. Harvard Pilgrim does not require prior authorization for covered epinephrine agents, but different tiers and quantity limits apply. We encourage providers to prescribe the generic versions of epinephrine 0.15mg and 0.3mg when possible for greater member affordability. As a reminder, there is a maximum quantity limit of two pens per fill in place for all brand and generic epinephrine agents. Throughout the commercial formularies, the different tiers of branded epinephrine agents (e.g., EpiPen 2-Pak, EpiPen-JR, Auvi-Q) range from high cost share tier to non-formulary. Depending on which formulary your patient’s plan has, certain branded epinephrine agents may require a formulary exception — and if they are approved, the patient would be responsible for a higher copayment. All epinephrine agents work the same, but they are available in different forms. Generic epinephrine, EpiPen 2-Pak, EpiPen-JR, and Auvi-Q are available as auto-injectors, and Auvi-Q has an additional feature that offers a voice instruction system to guide users through an injection. Symjepi, which is covered at a high cost share tier, is available as a prefilled syringe. To review coverage of a specific epinephrine product, please refer to the formulary lookup tool located within the Pharmacy section of Harvard Pilgrim’s provider website. Stride: Help Us Maintain Up-to-Date Problem Lists Harvard Pilgrim relies on up-to-date data from our providers to evaluate our performance as a health plan and the level of care provided to our members, your patients. The Centers for Medicare and Medicaid Services (CMS) recently announced that for the 2021 Star Ratings measurement year, under the advisement of the Pharmacy Quality Alliance, they are adding additional exclusions for the Statin Use in Persons with Diabetes (SUPD) Star
NETWORK MATTERS May 2021
Measure — and we request your partnership in ensuring that the ICD-10 codes for the
following newly excluded diagnoses are submitted to us, as appropriate:
• Rhabdomyolysis or myopathy
• Pregnancy, lactation, or fertility
• Liver disease
• Pre-diabetes
• Polycystic ovary syndrome
The SUPD measure assesses the percentage of individuals ages 40 to 75 years with prescription
claims for diabetes medications and a statin medication. Please note that these new exclusions
are in addition to the exclusion previously in place for members enrolled in hospice or those
with end-stage renal disease.
Harvard Pilgrim supports CMS’s decision to incorporate these new exclusions; while we agree
with the importance of statin use in the diabetic population, we understand that there are
clinical reasons individual members should not be treated with them.
By adding the ICD-10 codes related to these newly excluded diagnoses to our StrideSM (HMO)
Medicare Advantage members’ problem lists (lists of current and active diagnoses as well as
past diagnoses relevant to the current care of the patient) in medical records, you assist
Harvard Pilgrim in maintaining accurate information that helps us continue to provide high-
quality care.
Updates to Radiation Oncology Payment Policy
Effective beginning July 1, 2021, Harvard Pilgrim will apply frequency limits for a number of
radiation oncology procedure codes.
The following configuration edits are industry standard and based on guidance from the
American Society of Radiation and the Centers for Medicare and Medicaid Services:
• Deny 77427 (Radiation treatment management) when billed more than once in a five-
day period by any provider.
• Limit any combination of 77280-77290 (Therapeutic radiology simulation-aided field
setting) to five units in 56 days by any provider.
• Deny additional billings of 77295 (3-dimensional radiotherapy plan including dose-
volume histograms) when billed more than three visits in eight weeks.
• Limit any combination of 77332-77334 (Treatment devices, simple; intermediate;
complex) to seven units in 53 days by any provider and the diagnosis is not head and
neck cancer, or prostate cancer, and a complex therapy service has not been billed for
the same date of service or within two weeks (before or after).NETWORK MATTERS May 2021
• Limit any combination of 77332-77334 (Treatment devices, simple; intermediate;
complex) to twelve units in 53 days by any provider.
• Limit 77300 (Basic radiation dosimetry calculation) to six units per day by any provider
and the diagnosis is not head and neck cancer, prostate cancer or Hodgkin’s disease,
and a complex therapy service has not been billed for the same date of service or within
two weeks (before or after).
• Limit 77300 (Basic radiation dosimetry calculation) to six units in eight weeks by any
provider and the diagnosis is not head and neck cancer, prostate cancer or Hodgkin’s
disease, or a complex therapy service has not been billed for the same date of service or
within two weeks (before or after).
• Limit 77300 (Basic radiation dosimetry calculation) to ten units in 56 days by any
provider.
• Limit 77331 (Special dosimetry) to six units in 56 days by any provider.
• Deny additional billings of 77301 (IMRT plan) when billed more than one date of service
in 56 days.
• Deny MRIs and CTs when appended with modifier 26 (Professional component) and
billed with 77263 (Therapeutic radiology treatment planning; complex).
• Deny Q3001 (Brachytherapy element) when billed with remote after-loading high
intensity brachytherapy.
• Deny 77470 (Special treatment procedure [e.g., total body irradiation, hemibody
radiation, per oral or endocavitary irradiation]) when billed by any provider without a
qualifying diagnosis on the claim, and a complex therapy service has not been billed for
the same date of service or within two weeks (before or after).
For more information, please refer to Harvard Pilgrim’s updated commercial Radiation
Oncology Payment Policy.
Network Matters is a monthly newsletter for the Harvard Pilgrim provider network
Helen Connaughton, Director of Network Operations
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
