We want to make sure you get the right care in the right place. Our care managers and clinicians look at some of the services your doctors think you need before you get them, to see if they are medically necessary and if they are planned for the right type of facility. If necessary, we give your doctors prior authorization (permission) before you get certain services. We also review some of your services as you get them (e.g., if you go to the hospital) to make sure you get the best care. We work with you and your doctors to make a plan for when you leave a facility or stop getting services. Finally, we review your services after you get them to make sure you got the best quality care.
As part of our care management program, if you have a physical disability or other special health condition such as a high-risk pregnancy, cancer, HIV/AIDS or a behavioral health (mental health and/or substance use) concern, our clinicians can give you information and personalized resources (if eligible) and help coordinate your care. We also offer social care management services to help arrange, coordinate and evaluate the services you may need; and disease management programs for asthma and diabetes and health-coaching services if you have a chronic health condition.
For more on these services, check our Tufts Health Direct Member Handbook (PDF).