CurrentHarvard Pilgrim Health CarePolicy N/A

Allergy testing and immunotherapy reimbursement

This payment policy governs reimbursement for medically necessary allergy testing and immunotherapy services for Harvard Pilgrim Health Care and Tufts Health Plan products; it applies to contracted providers and is subject to member benefits and authorizations.

Policy Summary

PayerHarvard Pilgrim Health Care

PolicyAllergy testing and immunotherapy reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility and benefits and confirm applicable referrals, notifications, and authorizations prior to providing services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

200maximum allergy tests in 365 days (Public Plans & Senior Products)

30limit of 86003 within 365 days (Tufts Health Plan Products)

1facility billing limit per day (Commercial & Direct)

95004-95170key CPT ranges

Coverage and Medical Necessity

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.

Coverage and exclusions

Covered when ALL of the following are met:

Point32Health reimburses contracted providers for medically necessary allergy testing and treatment services.

Policy applies to Harvard Pilgrim Health Care and Tufts Health Plan products and affiliates; payment is subject to member benefits, eligibility, and provider agreements.

Services are provided in accordance with the member's benefit plan documents and are subject to applicable member cost sharing and eligibility verification prior to services.

Verify member eligibility and benefits prior to services.

Services are performed by contracted providers or in accordance with network participation requirements.

Use of non-contracted labs may expose members to inappropriate services or financial liability; Point32Health may hold ordering providers accountable for selection of nonparticipating labs.

Exclusions (NOT covered)

Environmental products and supplies for allergies (e.g., air conditioners, bed supplies, air filters)
Allergy tests or immunotherapy that have no proven health benefit or are considered experimental or not FDA-approved
Diet therapy, homeopathy, or sublingual immunotherapy for allergies
Duplicate services, including repeat percutaneous scratch tests, intradermal tests and patch tests billed to a facility

Billing rules

Multi-dose vial billing: when preparing a multi-dose vial of antigens for a patient for whom only one dose is injected, bill the entire number of doses in the vial and the appropriate injection service with a count of one.
For remaining doses in a multi-dose vial, bill only the appropriate injection service when those doses are injected.
Multi-dose billing rules apply regardless of who injects the preparation or where the injection takes place.

CPT/Procedure Codes and Limits

Allergy testing CPT codesCPTCovered

95004-95079

Allergy testing: Bill with a count representing the number of tests performed

Allergy immunotherapy CPT codesCPTCovered

95115-95134

Allergy Immunotherapy

Antigen preparation CPT codesCPTCovered

95144-95170

Antigen preparation: Bill with the specific number of doses prepared

Professional supervision CPT codeCPTCovered

95165

Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens

86003 units limit (Tufts Health Plan Products)

Limit detail30 units of 86003 within 365 days for Tufts Health Plan products.

Applies toTufts Health Plan Products (per policy limits).

Timeframe365-day rolling period as specified in policy.

Allergy test limit (Public Plans & Senior Products)

Maximum tests200 allergy tests (any combination of percutaneous and intradermal) within 365 days.

Applies toTufts Health Public Plans and Senior Products.

NoteDaily maximums may apply per policy guidance.

Facility daily testing limit (Commercial & Direct)

Facility billing limitOne unit of allergy testing per day when billed by a facility.

Applies toTufts Health Commercial and Tufts Health Direct products.

ScopeLimit applies specifically when services are billed by a facility rather than professional providers.

Authorization, Eligibility, and Billing Guidance

Prior Authorization

Prior Authorization and Eligibility

Verify member eligibility and benefits for the date of service prior to scheduling or providing services. Prior authorization, referral, notification, and utilization management requirements may apply per Point32Health (Harvard Pilgrim Health Care and Tufts Health Plan) provider manuals; check the member's plan and the Provider Manual for product-specific rules. An authorization, when required, must be obtained before services are rendered; note that an authorization is not a guarantee of payment. Payment remains subject to member eligibility, coordination of benefits, medical necessity determinations, provider network participation, and claims-editing logic. The Plan reserves the right to audit providers and to recover payments if documentation or billing do not comply with policy.

Verify eligibility and benefits on the date of service
Obtain prior authorization when required by the member's product and the Provider Manual
Confirm referral requirements for the member's plan before providing services
Document medical necessity and retain records in case of audit
Understand that authorization does not guarantee payment; claims remain subject to adjudication

Definitions

Allergy testing

DefinitionAllergy testing includes in vivo testing (skin allergy testing, bronchial provocation tests, and food challenges) and in vitro testing to identify allergen-specific IgE in blood serum.

In vivo examplesSkin testing, bronchial provocation tests, food challenges.

In vitro examplesLaboratory testing to detect allergen-specific immunoglobulin E (IgE) in serum.

Allergy treatment (Immunotherapy)

DefinitionAllergy immunotherapy includes antigens, extracts, and venoms used in treatment, and the preparation and/or provision of the allergy immunotherapy injection(s).

Included materialsAntigens, extracts, venoms (and enteral nutrition when medically necessary per related policies).

Services coveredPreparation and provision of allergy immunotherapy injections (including multi-dose vial preparation rules described elsewhere in policy).