Joint Surgery Prior Authorization Program
The Joint Surgery Prior Authorization Program applies to Tufts Health Plan Commercial products*, Uniformed Services Family Health Plan (USFHP), Tufts Health Public Plans products (including Tufts Health Direct, Tufts Health RITogether and Tufts Health Together – MassHealth MCO Plan and Accountable Care Partnership Plans). This program applies to Massachusetts and Rhode Island Commercial plan members.
*Commercial products include HMO, POS, PPO and Tufts Health Freedom Plan.
Note: USFHP is included in the Joint Surgery Program only and joint surgery codes are subject to National Imaging Associates' (NIA) prior authorization requirements.
Effective for dates of service on or after January 1, 2018, providers must request prior authorization for members (including members under 18 years of age) for hip, knee and/or shoulder surgeries through NIA’s website or by phone at 866.642.9703 for Tufts Health Plan products or 800.207.4209 for Tufts Health Public Plans products. Using evidence-based criteria and guidelines, NIA will review coverage requests and provide authorizations for the services listed below.
Prior authorization will be required for the following nonemergent inpatient and outpatient hip, knee and shoulder surgeries:
- 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, diagnostic hip arthroscopy, and extra-articular 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 synovectomy, loose body removal, diagnostic knee arthroscopy, debridement with or without chondroplasty, lateral release/patellar realignment, and articular cartilage restoration
- 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 debridement, manipulation, decompression, tenotomy, tenodesis, synovectomy, claviculectomy, and diagnostic shoulder arthroscopy
- It is the responsibility of the ordering physician to obtain prior authorization for all joint surgeries outlined above.
- 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.
- Any Tufts Health Plan inpatient admission notification requirements for the facility or hospital admission must be obtained separately and only initiated after the surgery has met NIA’s medical necessity criteria.
Services other than the joint surgeries outlined above will continue to follow Tufts Health Plan’s prior authorization requirements for hospital admissions and elective surgeries.
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. To obtain and verify authorizations or access medical necessity guidelines, log in to RadMD or call 866.642.9703 for Tufts Health Plan products or 800.207.4209 for Tufts Health Public Plans products.
For additional information on NIA’s Spinal Conditions Management Program prior authorization requirements and procedures, refer to the Spinal Conditions Management Programs Through NIA.
Note: This program does not apply to members of Tufts Medicare Complement, Commercial PPO plans with a PHCS or Cigna network, CareLinkSM, Tufts Medicare Preferred HMO, Tufts Medicare Preferred Supplement, Tufts Health Plan Senior Care Options or Tufts Health Unify.