Joint Surgery Prior Authorization Program

Tufts Health Plan requires providers to obtain prior authorization through National Imaging Associates' (NIA) for joint surgeries for members of the following Commercial and Tufts Health Public Plans products:

  • Commercial products, including HMO, POS, PPO and Uniformed Services Family Health Plan (USFHP)
  • Tufts Health Direct
  • Tufts Health Together – MassHealth MCO Plan and Accountable Care Partnership Plans
  • Tufts Health RITogether

Note: This program does not apply to members of Senior Products (including Tufts Medicare Preferred HMO and Senior Care Options [SCO]), Commercial PPO plans with a Cigna network, CareLinkSM, or Tufts Health Unify.

Prior Authorization for Hip, Knee and Shoulder Surgeries

While you may not be the provider responsible for obtaining prior authorization, as a condition of payment, you must confirm that prior authorization has been obtained. To request and verify authorizations or access medical necessity criteria, providers may log in to the NIA portal, RadMD, or call 866.642.9703 for Tufts Health Plan products or 800.207.4209 for Tufts Health Public Plans products.

Providers must request prior authorization for members (including members under 18 years of age) for the following nonemergent inpatient and outpatient hip, knee and shoulder surgeries. NIA will review coverage requests and provider authorization for the services:

Hip

  • Revision/conversion hip arthroplasty
  • Total hip arthroplasty/resurfacing
  • Femoroacetabular impingement (FAI) hip surgery (includes CAM/pincher & labral repair)
  • Other hip surgeries including synovectomy, loose body removal, debridement, and diagnostic hip arthroscopy

Knee

  • Revision knee arthroplasty
  • Total knee arthroplasty (TKA)
  • Partial-unicompartmental knee arthroplasty (UKA)
  • Knee manipulation under anesthesia (MUA)
  • Knee ligament reconstruction/repair
  • Knee meniscectomy/meniscal repair/meniscal transplant
  • Other knee surgeries including diagnostic arthroscopy, autologous chondrocyte implantation, Osteochondral Allograft/Autograft, Anterior tibial tubercleplasty, Reconstruction of Dislocating Patella, Lateral Release, Loose Body Removal, Synovectomy, Chondroplasty, and Microfracture

Shoulder

  • Revision shoulder arthroplasty
  • Total/reverse shoulder arthroplasty or resurfacing
  • Partial shoulder arthroplasty/hemiarthroplasty
  • Shoulder rotator cuff repair
  • Shoulder labral repair
  • Frozen shoulder repair/adhesive capsulitis
  • Other shoulder surgeries including diagnostic arthroscopy, Claviculectomy, Acromioplasty, Coracoacromial ligament release, Biceps Tenotomy/Tenodesis, Synovectomy, Debridement, Distal Clavicle Excision (Mumford procedure), Subacromial Decompression

Note: NIA does not manage prior authorization for emergency joint surgery cases that are admitted through the emergency department or for joint surgery procedures outside of those listed above.

Facilities or hospitals performing joint surgeries requiring inpatient admission must adhere to the Tufts Health Plan inpatient notification requirements. Inpatient notification must be obtained through Tufts Health Plan’s Precertification Department and only initiated after the surgery has met NIA’s medical necessity criteria. For more information, refer to the Inpatient Facilities Payment Policy for Commercial or Tufts Health Public Plans.

For a list of procedure codes subject to prior authorization by NIA, refer to the Spinal Conditions Management and Joint Surgery Program Prior Authorization Code Matrix or visit RadMD to access medical necessity guidelines.

Additional Information