Authorizations

Tufts Health Public Plans

We require prior authorization before you send someone to see one of our nonpreferred in-network or out-of-network providers, except for emergency, post-stabilization, and urgent care. To check which providers require prior authorization, see our Find a Doctor, Hospital, or Pharmacy tool.

We also require prior authorization for:

  • Certain covered services (e.g., inpatient admissions, some types of surgery)
  • Home health care
  • Durable medical equipment
  • Certain behavioral health services
  • Certain medications
  • Advanced radiology imaging services

To check if a service is covered and/or requires prior authorization, please see our medical and behavioral health benefit summary grids.

Please note: If you are a primary care provider, make sure the patient is in our records as part of your panel before rendering services. We require prior authorization for services rendered to a Tufts Health Public Plans member who is not in your panel.

How to request prior authorization

For members of Tufts Health Together (MassHealth) or Tufts Health Direct (an individual and small-group plan):

For members of Tufts Health Unify (Medicare-Medicaid One Care for people ages 21 – 64):

  • Pharmacy services, including specialty pharmacy drugs — please fill out the appropriate coverage determination request form and fax it to us at 617-673-0956 or call us at 888-257-1985
  • Medical and behavioral health services — please fill out the appropriate prior authorization request form and fax it to 857-304-6304, or call our Tufts Health Unify team at 888-257-1985
  • Advanced radiology imaging services — contact National Imaging Associates (NIA), an organization specializing in managing diagnostic services

To request other authorizations, please fill out the appropriate form and fax or mail it to us at:

Tufts Health Plan
Attn: Member Services
P.O. Box 9194
Watertown, MA 02471-9194

If an authorization request is urgent 

For urgent authorization needs, please call us at 888-257-1985.

Please check eligibility on the date of service; approval depends on eligibility and other determining factors. We do not pay for services rendered to patients who were not Tufts Health Public Plans members on the date of service.