Tufts Health Public Plans

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.