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.
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):
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.
Coding and Limits
| 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 |
| 20560-20561 | Needle insertion (dry needling) codes |
Referrals, Authorizations, and Provider Responsibilities
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
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.