Referral Requirements for Specialty Services

To help you get the care you need, your primary care provider (PCP) may need to refer you to a specialist Specialist: A specialist is a doctor who provides health care services for a specific disease or part of the body. .

There are many kinds of specialists, such as:

  • Oncologists: Treat patients with cancer
  • Cardiologists: Treat patients with heart conditions
  • Orthopedists: Treat patients with certain bone, joint or muscle conditions

Your provider will need to give us a written referral Written referral: A referral is an authorization (permission) that you need before you can use other providers in the plan’s network.  before you see some specialists. A referral helps both your PCP and your Tufts Health Plan care manager better guide the care and services you get from the providers you see, so that you get the best care and stay as healthy as possible.

Though you may not always need a referral from your provider to see a specialist, you should still discuss it with your PCP before you visit one. Your PCP can recommend a specialist and, if necessary, will request prior authorization (permission) Prior authorization: Also called “prior permission,” is the approval needed before you can get certain services or drugs. Some network medical services are covered only if your doctor or other network provider gets prior authorization from our plan. Covered services that need prior authorization are marked in the Benefits Chart in Chapter 4 of the Member Handbook. Some drugs are covered only if you get prior authorization from us. Covered drugs that need prior authorization are marked in the List of Covered Drugs.  from Tufts Health Plan in advance. You may visit most specialists without prior authorization as long as the specialist is a network provider. Please visit our Find a doctor tool for help finding an in-network provider.

Tufts Health Plan will review your PCP’s prior authorization request for an out-of-network provider. If we don’t give written approval for the request from a clinician for an out-of-network provider, we won’t cover the services.

If you still choose to get services from an out-of-network specialist, you’ll be responsible for payment. See Benefits & Costs for more information or refer to Chapter 4 of your Tufts Health Unify Member Handbook.

If you have questions about how to select a PCP or specialist, or to find out if you need prior authorization to see a specialist, call us toll-free at 855-393-3154 (TTY: 711), seven days a week, from 8 a.m. to 8 p.m or you can call your care manager for assistance.

H7419_4520_CMS Approved
Page modified on: 4/7/2016 6:57:05 PM