How We Help You Get the Quality Care You Need

Decisions are based on need and effectiveness

How we review requests

When we get requests, we review them based on up-to-date medical standards and your Tufts Health Plan coverage. As part of the review, we decide if the health care service is medically:

  • Necessary
  • Appropriate
  • Effective

Who the reviewers are

After a careful review, we decide about covering the service or treatment. Only qualified, licensed doctors or licensed psychologists, or pharmacists, when appropriate, make decisions to deny coverage for a service or treatment.

We don’t link compensation or reward reviewers to deny requests. Nor do we give financial incentives to encourage them to deny appropriate coverage or the under-use of health care services. We prohibit making decisions regarding hiring, promoting, or terminating employees based upon the likelihood or perceived likelihood that the individual will support or tend to support the denial of benefits.

To learn more

For more information about how we review requests to cover certain health care services, which we call utilization management, please read your SBC.