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Commercial Provider Manual

Authorizations

Overview

To ensure the quality of member care, Tufts Health Plan is responsible for monitoring authorization, medical appropriateness, and cost efficiency of services rendered. Certain services for members enrolled in HMO and POS products require a referral or authorization to confirm that the member's primary care provider (PCP) or Tufts Health Plan has approved the member's specialty care services. For HMO members, such authorization is a requirement for coverage, while for POS members it is a requirement for coverage at the authorized benefit level. A referral verifies that the PCP has authorized the member's care. The PCP is responsible for indicating the number of visits and type of specialty care services authorized. In most cases, a referral is valid in the Tufts Health Plan system for one year, or until the approved number of visits or member's benefit is exhausted. Note: Depending on the service, while you may not be the provider responsible for obtaining prior authorization, as a condition of payment, you will need to make sure that the prior authorization has been obtained.

Outpatient Referral Management

The PCP coordinates the outpatient referral management process to ensure that appropriate specialty care is provided when medically necessary. With the exception of mental health services (refer to the Mental Health and Substance Abuse payment policies), the PCP can authorize a standing referral to a specialist in the Tufts Health Plan network when: 1) he or she decides that such a referral is medically necessary, 2) the specialist agrees to a treatment plan and provides the PCP with all necessary clinical and administrative information on a regular basis, and 3) the health care services to be provided are consistent with the terms of the member's benefit document. A referral assures the specialist that the PCP has authorized the member's care. It also authorizes the Tufts Health Plan Claims Department to pay the specialist's claims. Except for the following, all specialty services require a referral authorization when performed by a Tufts Health Plan provider: Note: The following services may require authorization from either Tufts Health Plan or another approved vendor. · · · · · · · · · · · · Routine eye exam Annual gynecological exam and follow-up services Chiropractic services Durable medical equipment (DME)1 Emergency department services Home health care services1 Laboratory Imaging services Mental Health/Substance Abuse (MH/SA) -- Behavioral Health Services Observation room services Obstetrical care Oral surgery

1. These services require Tufts Health Plan's authorization.

Submitting an Outpatient Referral

Outpatient referrals can be submitted electronically via: · · tuftshealthplan.com/providers -- Register with Tufts Health Plan to take advantage of our online functionality. New England Healthcare EDI Network (NEHEN) -- Refer to the NEHEN Resource Document in the Electronic Services section of our website for additional information.

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Authorizations

·

Point of Service (POS) swipebox network -- Refer to the POS Resource Document in the Electronic Services section of our website for additional information. All services requiring referrals can be submitted via this option.

Note: Tufts Health Plan encourages referral submission through our website for instantaneous receipt of a referral number. To learn more about our web-based offerings, call 888-884-2404 and select the web inquiry option, or email us at [email protected] Additionally, outpatient referrals can be submitted on paper. A copy of the Outpatient Referral Authorization Form is shown on the next page. The table following the referral form outlines the fields on the referral form and gives any special information or instructions needed to complete the form. Note: Referrals authorizing more than one visit need only be submitted to Tufts Health Plan once, not with each subsequent date of service billed. FIGURE 17. Outpatient Referral Authorization Form

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TABLE 19. Fields on the Paper Referral Authorization Form

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Field # 1 2

Field Name Member name Date of referral

Explanation

Special Instructions First, last and middle initial This date must precede the date of service

3

Member identification number

Tufts Health Plan member ID number, from ID card or monthly member list

4

Birthdate

5

Referred from: Name of PCP Provider ID number

PCP's full name is required.

6

Address of PCP PCP phone #

7

Referred to: Name of specialty care physician/provider Referred to ID #

Provider's full name and ID # is required.

8

Address of specialty care physician/provider: Specialty

Referral status:

Check one

Tufts Health Plan provider (in-plan)

Referral made by a PCP to a specialist within the Tufts Health Plan network

Non-Tufts Health Plan provider (out-of-plan)

Referral made by a PCP to a specialist who is not affiliated with Tufts Health Plan

All out-of-plan referrals require PCP and physician reviewer approvals. State the diagnosis or presenting problem and list any diagnostic studies already performed. Diagnostic studies include labs, imaging, and special procedures.

Services requested Consultative opinion Field # Field Name Authorizes one specialty visit Explanation

Check one

Special Instructions

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Second surgical opinion Consultative opinion and diagnostic studies Consultative opinion, diagnostic studies and treatment Therapy (Physical Therapy, Occupational Therapy, Speech Therapy) Diagnostic studies to be performed at Signature of PCP; date Signature of physician reviewer; date

Authorizes one second opinion visit Authorizes up to three visits and includes diagnostics Enter the specific number of visits requested. If left blank, the default allowed is one visit. See Commercial Products in this section.

Location where diagnostic studies must be performed

Required for referrals to non-Tufts Health Plan Specialists and facilities

Distribution of Copies

If the PCP office does not submit referrals electronically, the PCP office is responsible for distributing the four copies of the referral authorization form as follows: Pink: PCP Light yellow: Specialist Dark yellow: Patient White: Use pre-addressed envelope (available at W.B. Mason, 508-436-8777) to mail to Tufts Health Plan

Services Provided without Referral Authorization and/or NonCovered

Tufts Health Plan requires members to be responsible for obtaining referrals to the extent required under the member's benefit package. For those products requiring such referral authorization or for services that are not covered by Tufts Health Plan, many offices have patients sign waiver forms, similar to the one found on the next page, to confirm the member's understanding of this policy. Note: A general type of waiver form (e.g.,"I agree to pay for anything that my insurance does not pay for") is not regarded as adequate to confirm the member's understanding and acknowledgement to proceed without a required referral or non covered service.

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FIGURE 18. Sample Provider Waiver Form

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Inpatient Preregistration

Tufts Health Plan covers medically necessary inpatient services that are preregistered in accordance with the time frame established by Tufts Health Plan. Outpatient procedures, including surgical day care and observation services, do not require preregistration. Preregistration does not guarantee payment by Tufts Health Plan. Tufts Health Plan requires prior authorization for certain services, drugs, devices, and equipment in order to be covered. Refer to the Clinical Resources section of our website to determine which services require prior authorization and the department that is responsible for review. Refer to the Authorization Policy on our website for preregistration procedures.

Preregistration Requirements

Tufts Health Plan requires a preregistration for any commercial member who is being admitted for inpatient care regardless of whether Tufts Health Plan is the primary or secondary insurer. An authorized initial length of stay and an authorized end date will be assigned for commercial admissions. Providers can log on to the Tufts Health Plan secure website to see these authorizations in real-time 24 hours a day, 7 days a week. If a provider is not webenabled or registered on the Tufts Health Plan secure website at the time of submission, he/she may request a faxed copy of their authorization. Note: Preregistration does not take the place of a referral or prior authorization requirements for a service. The following information is required when preregistering a member for inpatient care: · · · · · · · Patient's name Patient's Tufts Health Plan ID number Patient's date of birth Hospital name Attending physician name Date of admission and/or service Complete diagnosis and procedure information

When the preregistration process is complete, an authorized initial length of stay will be communicated as well as the authorized end date. The authorized end date is the date the authorized length of stay ends for the commercial acute inpatient and extended care admission. Tufts Health Plan may provide authorization for coverage of a continued stay; refer to the Continued Authorization section on the next page for additional information. The member's discharge date is the day after the authorized end date. The preregistration number will remain the same throughout the acute hospital inpatient event even when continued length of stay has been approved. For commercial extended care admissions, a new preregistration and number is created when there is a level of care change, e.g., from R1 to R2 or SNF level I to level II. Preregistrations submitted via fax will also be available for viewing on the provider website. The Precertification Department will no longer be routinely faxing back preregistration numbers to providers. If the provider preregisters the admission via telephone, the precertification staff will verbally communicate the preregistration number and the initial length of stay. This information will also be viewable on the Tufts Health Plan provider website.

Initial Length of Stay Assignment

The initial length of stay is based on the validity of the following: · · · · Member benefit and eligibility status Procedure Diagnosis Other medical information pertinent to the admission

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The initial length of stay will be assigned using criteria supplied by Thomson Reuters Healthcare (formerly Solucient). Thomson Healthcare's standards are based on all-payer data gathered from approximately 21 million actual inpatient records, representing one of every two discharges from U.S. hospitals annually. For mental health and substance abuse admissions, an initial length of stay will be authorized for one (1) day for psychiatric admissions and three (3) days for substance abuse admissions. Note: The accuracy of the length of stay assignment depends on the completeness and accuracy of the information submitted by the provider at the time of preregistration. If the assigned initial length of stay is zero, Tufts Health Plan will request clinical information from the hospital or admitting provider.

Continued Authorization

For inpatient facilities where Tufts Health Plan case managers obtain clinical information by phone or fax: · Acute Hospitals: To request additional inpatient days, submit the Acute Inpatient Continued Stay Clinical Information Form. The form should be used to submit clinical information, or as a guideline for the required information needed to conduct an InterQual review, to Tufts Health Plan by 5:00 pm on the day of the authorized end date. Mental Health and Substance Abuse Admissions: To request additional inpatient days, providers should contact their assigned Tufts Health Plan case manager by 5:00 pm on the day of the authorized end date to review their request. Extended Care Facilities: To request additional inpatient days, submit the Extended Care Inpatient Continued Stay Clinical Information Form--Initial and for subsequent additional days submit the Extended Care Inpatient Conintued Stay Clinical Infomation Form--Additional Form.

·

·

Continued stay requests and the accompanying clinical information must be submitted to Tufts Health Plan by 5:00 pm on the day of the authorized end date. Note: Tufts Health Plan will no longer send a Request for Information (RFI) to obtain clinical information on commercial admissions. For inpatient facilities where Tufts Health Plan case managers are on-site: · To request additional inpatient days, providers should contact their assigned Tufts Health Plan case manager to review their request.

Note: Commercial inpatient providers should contact their assigned Tufts Health Plan mase manager only if the member's inpatient stay is anticipated to exceed the authorized length of stay. If you have any questions about whether or not a preregistration is required for a particular member, contact the Tufts Health Plan Precertification Department at 800-672-1515.

After-Hours Urgent and Emergency Admissions

Urgent and emergency admissions occurring after business hours or on weekends and holidays are subject to the same notification criteria described in the Authorization Policy. Providers can use the following resources 24 hours a day, 7 days a week to preregister a member after hours: · · · · Log in to our secure website at tuftshealthplan.com. Access New England Healthcare EDI Network (NEHEN) (the provider must be a NEHEN member). Call 800-672-1515 (telephones are forwarded to an answering machine during non-business hours). Fax a completed preregistration form to the Precertification Department.

On the next business day, the precertification staff transcribes the admission information. They contact the physician or facility that initiated the preregistration process with the preregistration information or begin the research necessary to resolve a pending case. Tufts Health Plan requires a preregistration for any member who is being admitted for inpatient care regardless of whether Tufts Health Plan is the primary or secondary insurer, except for members enrolled in a Tufts Health Plan

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Medicare Complement Plan (TMC) or Medicare Complement Plan (MCP). The TMC and MCP plans do not require preregistration, except when applicable Medicare inpatient benefits have been exhausted. Note: PPO members whose care is managed through Private Health Care Systems (PHCS also known as Multiplan) network are preregistered for inpatient services through American Health Holdings (AHH), and not through the Tufts Health Plan Precertification Department. Providers can contact AHH at 866-415-7143.

Obstetrical and Newborn Preregistration Procedure

The following requirements apply to obstetrical and newborn patients (refer to our Authorization Policy on our website for additional information). · Pregnant women must be preregistered for delivery by 20 weeks gestation. To preregister, complete the Massachusetts Health Quality Partners (MHQP) Obstetrical Risk Assessment form and fax it to the Health Programs Department. This ensures that members receive all maternity benefits and are evaluated for participation in Healthy Birthday (Tufts Health Plan's preterm labor and delivery prevention program) and Tufts Health Plan's smoking-cessation for pregnant women program. Pregnant women with multiple inpatient admissions must be preregistered for each admission up to and including actual delivery. Well newborns are covered under the mother's preregistration for delivery. Sick newborns who will be staying in the hospital beyond the mother's discharge date must be preregistered separately within one business day following the discharge of the mother.

· · ·

For additional information, refer to our Obstetrics/Gynecology Payment Policy on our website.

Exclusions

If emergency room or observation care occurs without an inpatient admission, preregistration is not necessary.

Rescheduled Elective Admissions

If an elective admission is rescheduled, notify the preregistration staff of the change within the reporting time frame guidelines.

Admission to an Out-of-Plan Facility

When an HMO member requires an elective admission to an out-of-plan facility, approval for the admission must be obtained from both the PCP and physician reviewer. The Precertification Department contacts the physician reviewer to verify his or her concurrence with the admission. For HMO members, inpatient mental health and substance abuse care must be provided or arranged by the member's Designated Facility. Admission to an out-of-plan facility within the service area requires approval from the member's Designated Facility or Tufts Health Plan. For additional benefit and eligilibility information call the Tufts Health Plan Mental Health Department at 800-208-9565 or the member's Designated Facility.

Concurrent Review

The Tufts Health Plan case manager performs concurrent review using established screening criteria.

Payment and Denials

Only those hospital-based inpatient days that have been preregistered in accordance with this policy are eligible for payment by Tufts Health Plan. Emergency admissions that are preregistered within the next business day following hospitalization are considered to have been preregistered. Denial of payment for not following the preregistration policy will apply to both the hospital and related physician services. Denial of payment to physicians may be waived when the admission was the result of an emergency.

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Providers who are denied payment due to lack of preregistration cannot bill the member. However, providers can exercise their right to dispute by completing a payment dispute cover sheet and submitting the form along with a written letter sent to the address on the Tufts Health Plan Payment Dispute Policy.

Outpatient Mental Health and Substance Abuse

Coverage

Members' benefits vary according to employer group. Therefore members must refer to their Evidence of Coverage (EOC), or equivalent plan document, to determine their specific benefits. Benefit information can also be found by logging in to the secure provider section of our website and checking member eligibility or by calling the Mental Health Department at 800-208-8565. Employer groups can elect to "carve out" inpatient and outpatient mental health/substance abuse (MH/SA) benefits and contract them to a separately funded and administered managed mental health plan. In such situations, the mental health carve-out firm is responsible for the provision and maintenance of its own mental health provider network. Tufts Health Plan is not responsible for the reimbursement by or administration of such carve-out plans. Carve-out information is displayed on the member's ID card: the name is on the front and the telephone number is on the back.

Provider Responsibilities

Members whose EOC or equivalent plan document does not include coverage for out-of-network services must see a provider in the Tufts Health Plan network, except in highly unusual circumstances where the services are not available from an in-plan provider. Members with out-of-network coverage must see a provider in the Tufts Health Plan network if they wish to obtain the authorized level of benefits. The Tufts Health Plan outpatient MH/SA provider must obtain the necessary authorization number within 30 days of the member's first visit. To obtain authorization numbers, mental health providers can: · · Login to the secure provider section of the Tufts Health Plan website. Call 800-208-9565 to either use the interactive voice response (IVR) system or speak with a Mental Health coordinator.

Note: The member or the member's PCP can call to obtain the authorization number. It is the responsibility of the contracted MH/SA provider to ensure that the services are authorized. To obtain additional outpatient visits, mental health/substance abuse providers can: · · Login to the secure provider section of the Tufts Health Plan website. Use the IVR system by calling 800-208-9565 and refer to the Guide for Completing Mental Health Care Service Requests Using IVR.

Note: Utilization management is not performed for the initial set of visits. When members use their unauthorized level of benefits by receiving services with a non-contracted provider for routine outpatient mental health and substance abuse services, they are not required to obtain a mental health authorization. However, the member is responsible for applicable coinsurance and a deductible. If a member is discharged from a Tufts Health Plan Designated Facility (DF) to new outpatient services, the DF program may call a Tufts Health Plan mental health staff member to request a list of MH/SA providers who meet the member's needs. The provider is responsible for obtaining the initial authorization. When the authorization is almost exhausted, the MH/SA provider can request further visits from Tufts Health Plan as described above.

Backdating Authorizations

The Mental Health/Substance Abuse Program allows initial authorizations to be backdated up to 30 calendar days. Members, or someone acting on a member's behalf, may obtain an initial authorization for outpatient services; however, it is ultimately the responsibility of the treating provider to obtain the authorization within this time frame. The start date for requests for continued treatment (Tufts Health Plan Mental Health Clinical Service Request (MHCSR) requests) obtained through the Tufts Health Plan website or IVR systems can also be backdated up to 30 calendar days.

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Psychological and Neurological Testing

Psychological and neurological testing requires prior authorization for all products with the exception of CareLinkSM. To request prior authorization, providers must complete the Psychological and Neurological Testing Form.

Inpatient and Intermediate Level of Care Services for Mental Health and Substance Abuse

Commercial Products

Tufts Health Plan provides coverage for MH/SA inpatient, acute residential, partial hospitalization and intensive outpatient services as defined by the member's Evidence of Coverage (EOC) or equivalent plan document. Tufts Health Plan has established a Designated Facility Program. MH/SA Designated Facilities are a subset of Tufts Health Plan contracted facilities that are responsible for managing and coordinating both inpatient and intermediate levels of care for certain products. Reference the Designated Facility Manual for additional information. To determine the Designated Facility to which a member must be referred, log on to the secure provider section of our website and check member eligibility or call the Tufts Health Plan Mental Health Department at 800-208-9565 to access the IVR.

Substance Abuse

For substance abuse, Tufts Health Plan covers the cost of inpatient treatment, intensive outpatient, acute residential treatment, and partial hospitalization services provided or authorized by the member's Designated Facility according to the member's EOC or equivalent plan document.

Inpatient Mental Health and Substance Abuse Preregistration Procedure

MH/SA inpatient admissions are subject to all preregistration protocols and to the same timetable as other preregistration. For admissions, urgent and emergency admissions are defined as direct admission from the facility's emergency room. All MH/SA admissions require benefit and eligibility review by the Mental Health Program before a preregistration is authorized.

Intermediate Levels of Care MH/SA Registration Procedure

All intermediate levels of care require prior authorization through the member's Designated Facility or the Mental Health Department prior to the start of services. Providers can obtain authorization for intermediate levels of care by calling the Mental Health Department at 800208-9565. Designated Facilities can notify Tufts Health Plan of an admission by using the IVR at 800-208-9565.

Miscellaneous Prior Authorization Information

Certain services and procedures require prior authorization. Refer to the Clinical Resources section on the Tufts Health Plan website for a list of procedures that require prior authorization. Benefits can vary by employer group. Direct members either to their benefit booklets or to call Member Services for clarification.

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Specialty Care Services

Many of the following specialty care services have specific authorization guidelines on our website: Specialty Care Service Assisted Reproductive Technology (ART) Description · The Massachusetts Infertility Mandate of 1988 requires all commercial insurers and HMOs to cover non-experimental infertility or ART procedures for Massachusetts residents. As part of a member's benefit package, Tufts Health Plan covers appropriately authorized, medically necessary ART treatment, such as IVF, GIFT, and ZIFT. ART must beprovided by a Tufts Health Plan facility that is contracted specifically for ART. A member's PCP refers the member to a Tufts Health Plan specialist at one of the in-plan centers. For more information, call an ART specialist at 888-880-8699, ext. 3405. Due to variations by employer groups that are not subject to the Mandate, ART benefits are not included in some Preferred Provider Organization (PPO) or Point of Service (POS) benefit plans. Direct members to their benefit document or an ART specialist at 888-8808699, ext. 3405to determine individual coverage. Refer to the ART Payment Policy on our website for additional information. Medical Necessity Guidelines for all infertility services are also available on our website. Tufts Health Plan covers the purchase or rental of specified pieces of DME from Tufts Health Plan-designated vendors that have been selected based upon service, quality and cost. Tufts Health Plan decides whether to purchase or rent the equipment. Some items may require prior authorization through the Precertification Department or Case Management. See the Clinical Resources section of our website to obtain information about services and items that require prior authorization. To arrange for DME, the ordering physician has three options: - Directly contact the DME vendor listed in the Tufts Health Plan Provider Directory. - Contact the appropriate case manager who will help to make the necessary arrangements. - Fax a letter of medical necessity to the Precertification Department. Refer to the DME Payment Policy on our website for additional information. Early Intervention Services · Tufts Health Plan covers early intervention services for members until their third birthday only. Services must be rendered at an early intervention site approved by the Massachusetts Department of Public Health (DPH) (and Rhode Island Department of Human Services.) The member's PCP can authorize early intervention assessment services to the early intervention provider. Clinical review is not required. Members enrolled in Rhode Island plans can self-refer for early intervention services. Refer to the Early Intervention Payment Policy on our website for additional information.

·

· · Durable Medical Equipment (DME) ·

·

·

·

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Specialty Care Service Emergency Services

Description · Tufts Health Plan covers services provided to a member for emergency medical conditions. An emergency is defined as an illness or medical condition, whether physical or mental, that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in serious jeopardy to physical and/or mental health, serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or in the case of pregnancy, a threat to the safety of the member and her unborn child. Members are not required to obtain prior authorization from their PCP before going to the emergency room. However, members are encouraged to contact their PCP within 48 hours after receiving care in an emergency facility so that he/she can provide or arrange for followup care. In addition, if members are admitted as inpatient from the emergency room, the member (or someone acting for the member) should call the PCP or Tufts Health Plan within 48 hours after receiving care. Refer to the Emergency Room Payment Policy on our website for additional information. Tufts Health Plan covers the cost of medically necessary skilled nursing visits and short-term rehabilitative services for the homebound patient. A Tufts Health Plan case manager must authorize these services in advance, and a contracted home health care agency must provide the services. To receive authorization, providers can refer a member to a contracted agency listed in the Tufts Health Plan Provider Directory. The agency must contact the appropriate case manager at Tufts Health Plan for authorization. Refer to the Home Health Care Payment Policy on our website for additional information. Some injectables may require prior authorization through the Pharmacy Management Program and/or may require that members obtain it through a Tufts Health Plan designated specialty pharmacy. Tufts Health Plan will provide coverage for lactation consultants up to $75 per visit for up to a total of 3 visits per pregnancy. The member must pay up front for services, and apply for reimbursement through Member Services. Tufts Health Plan covers the cost of nutritional counseling when authorized by the PCP. Services must be rendered by a Tufts Health Plan provider who is a registered dietitian, and are subject to certain benefit limits. Members must obtain referral authorization from their PCP. For exclusions to this benefit, contact Member Services.

·

·

Home Health Care

·

· · ·

Injectables

·

Lactation Consultants

·

Nutritional Counseling

·

Specialty Care Service OB/GYN Services

Description · Tufts Health Plan members are not required to obtain referrals or prior

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authorization from their PCP for the following OB/GYN services provided by participating obstetricians, gynecologists, certified nurse midwives, or family practitioners: - Maternity care - Medically necessary evaluations and related health care services for an acute or emergency gynecology condition - Routine annual gynecological exam, including any follow-up obstetrics and/or gynecology (including certified nurse midwives and family practitioners) · Once a member has self-referred to a participating provider who specializes in obstetrics and/or gynecology (including certified nurse midwives and family practitioners), any further referrals to other providers must be obtained through the PCP. Preregistration is required for inpatient services. Refer to the Obstetrics/Gynecology Payment Policy on our website for additional information.

· Outpatient Rehabilitation

Physical Therapy · A PCP referral is required, if applicable, for one initial therapy evaluation in addition to a maximum of eight (8) medically necessary physical therapy visits for diagnoses that are appropriate for physical therapy services. To obtain prior authorization for continuation of treatment beyond eight physical therapy treatment visits, physical therapy providers must complete the Physical Therapy Authorization Form, and submit it to the Tufts Health Plan Precertification Department. For additional information, refer to the Physical Therapy Payment Policy on our website.

·

Occupational Therapy · A PCP referral is required, if applicable, for the initial occupational therapy evaluation and treatment. The PCP referral authorizes occupational therapy treatment to be rendered in accordance with the Tufts Health Plan short-term rehabilitation benefit. Occupational therapy providers must complete the Occupational Therapy Authorization Form, and submit it to the Tufts Health Plan Precertification Department to obtain prior authorization for continuation of treatment beyond 60 days from the date of the member's first therapy treatment visit. For additional information, refer to the Occupational Therapy Payment Policy on our website.

·

Oral Health

·

Tufts Health Plan offers a limited oral surgery benefit. Members can obtain care for covered procedures in a Tufts Health Plan oral surgeon's office on an ambulatory or inpatient basis. No referral is needed for outpatient services. Preregistration is required for inpatient admissions. Refer to the Oral Surgery Payment Policy on our website for additional information.

· · Speech Therapy

Speech Therapy · Speech therapy is covered with a PCP referral for up to 30 visits for medically based conditions. If the condition is not classified as

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medically based, the treating therapist may submit a Tufts Health Plan Speech Therapy Evaluation and Authorization form prior to initiation of treatment. The Precertification Department determines if speech therapy is covered for the member's condition, and if so, authorizes up to 30 visits. The treating therapist must submit requests for visits beyond 30. Both a PCP referral and prior authorization through the Precertification Department are needed for any and all visits beyond the 30 visits. · · Vision Care Program · Speech Therapy Medical Necessity Guidelines is available on our website. Refer to the Speech Therapy Payment Policy on our website for additional information. Eligible Tufts Health Plan members can go to a contracting EyeMed Vision Care ophthalmologist or optometrist for routine eye exams and optometry medical services. Routine eye exams do not require a referral. For additional information regarding contracting vision care providers, refer members to either Tufts Health Plan's Provider Directory or Member Services. Refer to the Vision Services Payment Policy on our website for additional information.

·

·

Last updated 05/2012. Chapter revision dates may not be reflective of actual policy changes.

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Authorizations

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