Note: This information is intended to provide an overview. Providers are reminded to check the member’s ID card to verify the plan in which the member is enrolled. Services and subsequent payment are pursuant to the member's benefit plan document. Prior to initiating services, member eligibility and benefits should be verified by logging on to the secure Provider website.
For information on Complaints, Grievances and Appeals processes see the Complaints, Grievances and Appeals page.
Most plans cover appropriately authorized, medically necessary services in full, minus the applicable copayment, deductible and/or coinsurance. Cost-share amounts vary by plan design and can be verified by using one of the electronic services options. For more information on network coverage, refer to the Use of Out-of-Network Providers Policy.
An inpatient notification is required for all inpatient admissions prior to rendering services. Prior authorization by Tufts Health Plan’s Precertification Operations Department is required for certain procedures and services. For a complete description of Tufts Health Plan’s authorization and notification requirements, refer to the Commercial Authorization Policy and the Referrals, Prior Authorizations and Notifications chapter of the Commercial Provider Manual.
Tufts Health Plan covers medically necessary outpatient, inpatient and intermediate services for behavioral health and substance use disorders (BH/SUDs), as defined by the member’s benefit plan document. For information on BH/SUDs, refer to the Outpatient BH/SUD Professional Payment Policy, the Inpatient and Intermediate BH/SUD Facility Payment Policy or the Behavioral Health section.
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