Currentharvard pilgrim health carePolicy N/A

Assisted Reproductive Technology (ART)

Defines reimbursement, global payment rules, separately reimbursable services, non-reimbursed services, provider billing requirements, and example CPT/HCPCS codes for ART services for Harvard Pilgrim Health Care and Tufts Health Plan commercial products and affiliated lines of business.

Policy Summary

Payerharvard pilgrim health care

PolicyAssisted Reproductive Technology (ART)

Policy CodePolicy N/A

Change Typerevised

Effective DateN/A

Next Review DateN/A

Key ActionSubmit claims using the NPI number assigned for ART services as both the provider and payee; claims will deny if any other NPI is used.

SourceLink

POLICY UPDATE CHANGES

Policy moved to new template; includes all lines of business.

globalGlobal Rate Scope

24 monthsCryopreservation storage included

30 daysCancelled cycle prior auth window (Tufts Commercial)

1One global fee per completed cycle

Policy scope and summary

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Scope: This policy applies to Harvard Pilgrim Health Care and Tufts Health Plan commercial products and affiliates. Payment is based on the member's benefits and eligibility on the date of service, applicable medical necessity determinations, the provider's contract with the Plan, and any required referrals/authorizations.

Reimbursement approach: Point32Health reimburses contracted providers for medically necessary infertility/ART treatment when treatment is reasonably likely to result in viable offspring. Claims payment is subject to member benefits, medical necessity review, applicable authorization requirements, coordination of benefits, and contractual fee schedules; an authorization is not a guarantee of payment.

Global rate concept: Many ART procedures and related services may be paid at an all-inclusive global rate that encompasses procedures (e.g., in‑vitro fertilization, assisted embryo hatching, donor oocyte procedures) and related services (e.g., anesthesia, facility/OR/recovery charges, laboratory testing during an active ART cycle, ultrasound, nursing, embryo preparation, pre/post‑surgical services). Providers performing ART-related services should not bill those services separately to the Plan; payment is included in the ART provider's global reimbursement.

Exceptions and operational rules: Certain services may be reimbursed separately (for example, initial evaluation, laparoscopy/hysteroscopy, MESA, or a confirmatory E&M visit billed with diagnosis Z32.01). A cycle is considered complete at successful egg retrieval for counting purposes, but for billing the global payment covers services through the pregnancy test. Providers must submit claims using the ART-specific NPI, bill one global fee per completed cycle (except HCPCS S4025 for egg donor services), and follow the Plan's cancelled-cycle prior authorization timing (e.g., Tufts Commercial: request within 30 days).

Summary

PayerHarvard Pilgrim Health Care and Tufts Health Plan (commercial products)

Policy titleAssisted Reproductive Technology (ART) billing and reimbursement

Policy numberN/A

Effective Date

Scope summaryDefines reimbursement, global payment rules, separately reimbursable services, non-reimbursed services, provider billing requirements, and example CPT/HCPCS codes for ART services for Harvard Pilgrim and Tufts Health Plan commercial products and affiliates.

Key policy pointsGlobal rate applies to multiple ART procedures; One global fee per completed cycle (except HCPCS S4025 for egg donor services); Cancelled cycle prior auth window: 30 days (Tufts Health Plan Commercial); Submit claims using ART-specific NPI for provider and payee; A cycle counts against lifetime total whether completed or cancelled; For billing, cycle covers services up to pregnancy test.

Reimbursement preconditions and coverage rules

General Reimbursement Preconditions

Point32Health reimburses contracted providers for diagnosis and medically necessary treatment of infertility when treatment is reasonably likely to result in viable offspring. Billing and global rate rules apply as follows:

Member eligibility and benefits: Member must be covered under applicable product and have benefits for infertility/ART services (verify eligibility and benefits prior to services).
Supported by general benefit and coverage statements in policy.
Contracted provider requirement: Services must be performed by contracted providers.
Providers must be contracted as indicated in policy.
Medical necessity and authorization: Services must meet applicable medical necessity criteria and any applicable referral/notification/authorization policies.
Refer to applicable medical necessity guidelines and prerequisite policies.
Cycle counting and billing scope: A cycle is counted against the member's lifetime total regardless of completion or cancellation; a cycle is considered complete at successful egg retrieval for counting; for billing, all services up to positive/negative blood pregnancy test are part of the cycle and covered by the global payment.
Cycle definition and billing scope per policy.

Cancelled Cycle Billing (Tufts Health Plan Commercial members)

Requirements to request coverage for a cancelled cycle (Tufts Health Plan Commercial members):

Request timing and form: Providers must request coverage of a cancelled cycle within 30 days of the cancelled procedure(s) by submitting the Infertility Services Prior Authorization Request form with the appropriate HCPCS code(s).30 days
Tufts Health Plan Commercial-specific requirement.

Global Rate Inclusion

ART procedures and many related services are included in an all-inclusive global rate (providers should not bill these separately):

Procedures included: Assisted embryo hatching (e.g., CPT/HCPCS 89253 is not separately reimbursed when part of cycle).
Policy lists assisted embryo hatching as included in global rate.
Donor oocyte procedure
Included in global rate list.
IVF: In-vitro fertilization (e.g., HCPCS S4011)
HCPCS S4011 listed under ART procedures.
GIFT: Gamete intra-fallopian transfer

Services Reimbursed Separately

Services that may be reimbursed separately from the ART global rate:

Initial evaluation for ART services
Listed as reimbursed separately.
Laparoscopy and hysteroscopy procedures
Listed as reimbursed separately.
MESA: Micro Epididymal Sperm Aspiration (MESA)
Listed as reimbursed separately.
Confirmatory E&M office visit after completion of an infertility service once the member is pregnant must be billed with diagnosis code Z32.01 or may be denied.
Diagnosis code Z32.01 requirement noted.

Non-Reimbursed Services

Services and items Point32Health does not reimburse:

LH ovulation kits: Luteinizing hormone (LH) ovulation kits
Not reimbursed per policy.
Donor egg non-contracted: Donor egg obtained from non-contracted providers
Not reimbursed.
Donor sperm without male partner infertility: Donor sperm and/or insemination procedures used to substitute for lack of a male partner when there is no medical diagnosis of infertility or when the male partner has been voluntarily sterilized
Not reimbursed.
Non-diagnosis infertility:

Relevant CPT / HCPCS codes and examples

Examples of codes not an all-inclusive list (not separately reimbursed when part of ART/global rate)CPT|HCPCSNot Covered

36415	Venipuncture. Not separately reimbursed when billed with blood or related laboratory tests or with E&M services.
36416	Collection of capillary blood specimen. Not separately reimbursed.
89253	Assisted embryo hatching, micro techniques (any method). Not separately reimbursed.
89258	Cryopreservation, embryo(s). Typically includes up to 24 months of storage.
89259	Cryopreservation, sperm. Typically includes up to 24 months of storage.
89337	Cryopreservation, mature oocyte(s). Typically includes up to 24 months of storage.
Q0091	Specimen collection. Not separately reimbursed when billed with laboratory tests or with E&M services or when billed by a facility.
S4011	In vitro fertilization; including identification and incubation of mature oocytes, fertilization, incubation of embryo(s), visualization for development. Any incomplete donor cycle should be billed with appropriate incomplete codes S4017, S4020 or S4021.
S4026	Procurement of donor sperm from sperm bank-per vial. Attach sperm bank invoice.
S4011	In vitro fertilization; including identification and incubation of mature oocytes, fertilization, incubation of embryo(s), visualization for development.

Billing rules, documentation, and operational requirements

Billing Rule

Use ART-specific NPI for claims

Submit claims using the NPI number assigned for ART services as both the provider and payee; claims will deny if any other NPI is used.

Billing Rule

One global fee per completed cycle

Submit claims for a cycle only when the cycle is complete; only one global fee can be billed per cycle regardless of number of services, except HCPCS S4025 (egg donor services for IVF).

S4025

Billing Rule

Cancelled cycle claim timing (Tufts Health Plan Commercial)

Request coverage of a cancelled cycle within 30 days of the cancelled procedure(s) using the Infertility Services Prior Authorization Request form with appropriate HCPCS code(s).

Submit Infertility Services Prior Authorization Request form within 30 days

Denial Risk

Do not separately bill ART-related services performed by non-ART providers

Non-ART providers (e.g., laboratories, anesthesiology) should not submit separate bills to Point32Health for services included in the ART global rate; such submissions are subject to post-payment audit and retraction.

Submissions by non-ART providers are subject to post-payment audit and retraction

Documentation Required

Confirmatory pregnancy visit diagnosis code

A confirmatory E&M office visit after completion of an infertility service once the member is pregnant should be billed using diagnosis code Z32.01; failure to use Z32.01 may cause a denial.

Z32.01
May be denied if Z32.01 is not used

Billing Rule

Attach sperm bank invoice for S4026

When billing HCPCS S4026 (procurement of donor sperm from sperm bank-per vial), attach the sperm bank invoice.

S4026
Attach sperm bank invoice

Claim Submission Rules

Operational billing requirements and claim-level rules:

Use ART-specific NPI: Submit claims using the NPI assigned for ART services as both the provider and payee; claims will deny if any other NPI is used.
Provider billing guideline.
One global fee per completed cycle: Submit claims for a cycle only when the cycle is complete (one global fee billed per cycle, except HCPCS S4025 for egg donor services for IVF).
Only one global fee per completed cycle except S4025.
Incomplete/cancelled cycle claims: Submit claims for an incomplete cycle only if a cycle is cancelled/terminated (canceled cycle billing may occur during endocrine monitoring and after attempted or completed egg retrieval).
Canceled cycle billing rules.

Key terms

Definitions

CycleAn ART cycle is considered complete at successful egg retrieval; for billing, services up to the pregnancy test are part of the cycle; any initiated cycle, completed or cancelled, counts against the member's lifetime total.

Global RateAn all-inclusive payment to the ART provider that encompasses ART procedures and related services (e.g., embryo services, anesthesia, diagnostics, lab tests, facility charges); providers performing ART-related services should not bill separately.

Policy changes and publication history

12/01/2025revised

Policy moved to new template; includes all lines of business.

Policy Summary

Payerharvard pilgrim health care

PolicyAssisted Reproductive Technology (ART)

Policy CodePolicy N/A

Change Typerevised

Effective DateN/A

Next Review DateN/A

Key ActionSubmit claims using the NPI number assigned for ART services as both the provider and payee; claims will deny if any other NPI is used.

SourceLink

On This Page

Listed as part of global rate.

ZIFT: Zygote intra-fallopian transfer

Listed as part of global rate.

Anesthesia and preparatory testing: Anesthesia services and preparatory testing when part of the ART cycle

Related services included in global rate.

Diagnostic testing when part of the ART cycle

Listed as included.

Embryo preparation/catheter loading

Included.

E&M services: Evaluation and management services when part of the ART cycle

Included.

Facility charges including OR/recovery and supplies

Included.

Laboratory tests (including semen analysis and sperm antibody tests) during an active ART cycle

Included.

Drugs: Non-self-administered drugs related to the ART service

Included.

Monitoring: Ovulation induction monitoring

Included.

Pre-post surgical: Pre- and post-surgical services

Included.

Radiology: Radiological procedures when part of the cycle

Included.

Surgical procedures (retrieval and transfer) and management including technical and professional components

Included.

Ultrasound for follicular maturation

Included.

Infertility services for members who do not have a diagnosis of medical infertility

Microsurgery reversal: Microsurgery and/or reversal of voluntary sterilization

Not reimbursed.

Ovulation prediction kits

Not reimbursed.

Surrogacy: Any form of surrogacy or services for a gestational carrier other than covered maternity services

Not reimbursed.

Sperm identification nonmedical: Sperm identification when not medically necessary (e.g., gender identification)

Not reimbursed.

Self-admin drugs exclusions: Self-administered prescription drugs when member does not have infertility as a covered benefit, lacks the prescription drug rider, or is not in an active and authorized infertility treatment or cycle

Not reimbursed under these conditions.

Non-ART providers separate billing: Non-ART providers who perform ART-related services (e.g., labs, anesthesia) — these services are included in the ART provider's global rate and not reimbursed separately

Policy states these services are reimbursed by ART provider and not separately.

Non-medical donor egg costs: Non-medical services related to donor egg procurement (finders' fees, broker fees, legal fees)

Not reimbursed.

Specimen collection/venipuncture: Specimen collection or venipuncture charges made in conjunction with laboratory services or E&M services

Not reimbursed when billed with lab or E&M services per coding guidance.

Shipping handling: Shipping and handling charges

Not reimbursed.

Facility should submit one claim: ART facility should submit one claim for the complete cycle; professional/technical services by outside practitioners should be billed to the ART provider, not to Point32Health separately.

Facility billing guidance; other providers should bill ART provider.

Audit note: Services billed by other providers that are included in the ART global reimbursement are subject to post-payment audit and retraction.

Post-payment audit and retraction note.