Tufts Health Plan's utilization management (UM) guidelines are intented to help providers manage care in an efficient manager with high quality standards. Refer to the Utilization Management Guidelines chapter for information about:
- Role of Plan Provider
- Utilization Management Program
- Medical Necessity and Clinical Criteria
- Medical Technology Assessment Process
- Access and Coverage System for Medical Affairs Department Physicians
- Role of Provider Unit Physician Reviewers (Massachusetts)
- Outpatient Services Review
- Retrospective Code Review
- Behavioral Health Intermediate Levels of Care Service Review
- Inpatient Services Review
- Medical Care Management and Discharge Planning
- Behavioral Health Care Management and Discharge Planning
- Referral to BH Case Management Programs
- Data Requirements: Clinical Information
- Determinations of Coverage
- Reconsideration
- Commercial Condition Management Programs
- Behavioral Health Care Management Programs
- Transition to Home Program
- Behavioral Health and Medical Integration Program
- Emergency Department Aftercare Program
- Substance Use Transitions Program
- Emergency Services
- Definition
- Emergency Services “Prudent Layperson” Standards