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).