Tufts Health Plan has reinstated prior authorization requirements for the following services, which apply to all diagnoses, except for a COVID-19 diagnosis
, for which specific guidance is outlined above:
- Hospice services. Refer to the Hospice Services Payment Policy for Commercial, Senior Products or Tufts Health Public Plans for additional information.
- Elective inpatient treatment or outpatient scheduled surgeries or admissions to acute care hospitals or mental health hospitals.
Effective for dates of service on or after August 7, 2021, Tufts Health Plan is reinstating prior authorization requirements for non-hospital locations for post-acute care (i.e. inpatient rehab, LTAC, skilled nursing facilities and home care), including following an inpatient hospital admission for Commercial Products, Tufts Health Direct, Tufts Health RITogether and Tufts Health Medicare Preferred HMO.
As a reminder, urgent/emergent admissions are never subject to prior authorization.
Behavioral Health Services
Effective for dates of service on or after June 1, 2021, prior authorization and notification is reinstated for the following behavioral health services for Massachusetts products:
- Applied Behavioral Analysis (ABA) for all Massachusetts products
- Children’s Behavioral Health Initiative (CBHI) for Tufts Health Together
- Behavioral Health for Children and Adolescents (BHCA) for Massachusetts Commercial products
Unless otherwise extended by state orders, effective for dates of service on or after July 9, 2021, prior authorization and notification is reinstated for the following behavioral health services for Rhode Island products:
- Applied Behavioral Analysis (ABA) for all Rhode Island products
- Home-Based Therapeutic Services (HBTS) for Tufts Health RITogether
- Psychology/Neuropsychology testing and rTMS for Rhode Island Commercial products
Providers are still responsible for confirming the service is covered by the individual treatment plan and the member meets medically necessary criteria for the service.