Currentharvard pilgrim health carePolicy N/A

Acupuncture reimbursement

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This payment policy governs reimbursement for acupuncture services for Harvard Pilgrim Health Care / Tufts Health Plan products and affiliates, specifying covered services, limits, billing and documentation expectations for contracted providers.

Policy Summary

Payerharvard pilgrim health care

PolicyAcupuncture reimbursement

Policy CodePolicy N/A

Change TypeCoverage removalrevision

Effective DateN/A

Last ReviewNov 1, 2025

Next Review DateN/A

Key ActionFollow applicable referral, notification and authorization procedures; authorization is not a guarantee of payment.

SourceLink

POLICY UPDATE CHANGES

Tufts Health Direct will not have coverage for acupuncture services, effective for dates of service beginning Jan. 1, 2026.

Corrected language for visit limitation of Senior Products from 12 month period to calendar year to align with benefit document.

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

Currentharvard pilgrim health carePolicy N/A

Acupuncture reimbursement

Customize your policy alerts

Sign up for all harvard pilgrim health care policy alerts

Know when harvard pilgrim health care releases new policies or updates existing guidance.

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Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

Payerharvard pilgrim health care

PolicyAcupuncture reimbursement

Policy CodePolicy N/A

Change TypeCoverage removalrevision

Effective DateN/A

Last ReviewNov 1, 2025

Next Review DateN/A

Key ActionFollow applicable referral, notification and authorization procedures; authorization is not a guarantee of payment.

SourceLink

POLICY UPDATE CHANGES

Tufts Health Direct will not have coverage for acupuncture services, effective for dates of service beginning Jan. 1, 2026.

Corrected language for visit limitation of Senior Products from 12 month period to calendar year to align with benefit document.

Coverage Criteria

Coverage criteria

Covered when ALL of the following apply (product-specific exceptions and limits noted):

Acupuncture services are reimbursed when medically necessary and when the service is a covered benefit per the member's plan documents.

Provider requirements: services must be performed by contracted/licensed providers with a specialty or subspecialty of acupuncture.

Benefit verification: coverage and member cost sharing (copayment, coinsurance, deductible) are subject to the member's benefit plan documents and should be verified prior to providing services.

Product-specific provisions

Tufts Health Direct: Acupuncture will not be a covered benefit for Tufts Health Direct members effective for dates of service beginning Jan. 1, 2026.
Senior Products: Acupuncture (including dry needling) may be covered for chronic low back pain in accordance with Medicare NCD 30.3.3 (Acupuncture for Chronic Low Back Pain).
Senior Products: Any combination of 20560-20561 or 97810-97814 billed more than 20 times within a calendar year by any provider is limited; medical necessity must be supported for volumes above this threshold.

Per-visit unit limit: A maximum of three acupuncture service codes or a total of three units in any combination are allowed per visit.

Modifier and visit documentation for Senior Products: Submit modifier KX to indicate medical necessity for all visits beyond the initial 12 visits within 90 days.

Supplies: Acupuncture needles are considered inherent to the acupuncture service and are not reimbursed separately.

Authorization and administrative: Applicable Point32Health referral, notification and authorization policies and procedures apply; an authorization is not a guarantee of payment. Providers are reimbursed according to contracted rates and must follow documentation requirements and provider manuals.

Coding and Limits

Covered CPT Codes - AcupunctureCPTCovered

97810	Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes
97811	Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes
97813	Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes
97814	Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes

Dry needling / Needle insertionCPT

20560-20561

Needle insertion (dry needling) codes

Per-visit unit limit

Per-visit unit limitMaximum of three acupuncture service codes or total of three units in any combination per visit

Applicable codesIncludes CPT/HCPCS acupuncture codes (e.g., 97810-97814) and needle insertion codes when billed as acupuncture services

EnforcementLimit applies at the claim/visit level regardless of code combination

Annual provider limit

Annual provider limitAny combination of 20560-20561 or 97810-97814 billed more than 20 times within a calendar year by a single provider is limited

Applies toSenior Products (per policy Senior Products section)

Referrals, Authorizations, and Provider Responsibilities

Prior Authorization

Referrals, Notifications and Authorizations — follow Point32Health procedures; authorization not a payment guarantee

Applicable Point32Health referral, notification and authorization policies and procedures apply; providers must follow the appropriate sections in the Provider Manuals for referrals, notifications and authorizations. Note that an authorization is not a guarantee of payment — payment remains subject to member eligibility, benefits, medical necessity review, coordination of benefits, and other plan requirements.

Follow Point32Health referral/authorization procedures as described in the Provider Manuals.
An authorization does not guarantee payment; claims remain subject to eligibility, benefits, medical necessity and other plan rules.

Definitions and Exclusions

Authorization

Authorization not a guaranteeAn authorization is not a guarantee of payment; payment depends on member eligibility, benefits, medical necessity review, and claims edits

Policy applicabilityAuthorization and referral requirements follow applicable Point32Health policies and procedures

Audit and complianceClaims remain subject to audits and repayment if noncompliance is found

Acupuncture supplies

Supplies reimbursementNeedles used in acupuncture are considered inherent to the service and are not reimbursed separately

Coding noteNeedle supply charges should not be billed in addition to acupuncture CPT codes (e.g., 97810-97814)