Claims and Referrals

Tufts Health Public Plans

Claims information

For claims related information, please refer to the following:

Referral requirement for specialty services

As part of our ongoing commitment to improving the connection between our members and their primary care providers (PCPs), we will require a PCP referral for specialty services beginning with dates of service January 17, 2011, for some members, starting with those in a Cambridge Health Alliance PCP panel.

The referral requirement applies to professional services; outpatient hospital visits; surgical day care; and initial visits or evaluation for physical therapy, speech therapy, and occupational therapy. It does not include inpatient care, emergency care, outpatient behavioral health services, or OB/GYN and family planning services.

We will not pay for specialty services that do not have a PCP referral when such a referral is needed. Please remember, you cannot bill members for these services.

The Tufts Health Public Plans member's PCP must notify us when specialty care is needed from a contracted specialist; we will then issue a referral number to the PCP. Specialists can check which Tufts Health Public Plans members require a referral when checking member eligibility with Tufts Health Provider Connect, our online provider service; NEHEN; and NEHENnet. Specialists can also check the status of a referral using Tufts Health Provider ConnectNEHEN, and NEHENnet

Our existing prior authorization rules remain unchanged. If a prior authorization is required, a referral is not.

Note: Information on this page is intended only for Tufts Health Public Plans products.