Currentharvard pilgrim health carePolicy thpp-06-um-pm

thpp-06-um-pm

Defines utilization management program structure, medical necessity guideline use, prior authorization requirements and processes (initial, concurrent, expedited), continuity of care and transition rules for various Tufts Health Public Plans products, discharge planning requirements, appeals/peer-to-peer and retrospective review policies, and lists services that do and do not require prior authorization.

Policy Summary

Payerharvard pilgrim health care

Policythpp-06-um-pm

Policy CodePolicy thpp-06-um-pm

Change TypeAdministrative updates (no material clinical changes)

Effective Date

Next Review Date

Key ActionProviders must obtain prior authorization for services listed under 'Services Requiring Prior Authorization'; failure to obtain PA may result in claims not being paid.

SourceLink

POLICY UPDATE CHANGES

01/01/24 - Updated plan name to Tufts Health One Care.

06/12/24 - Replaced 'National Imaging Associates, Inc./NIA' with 'Evolent'; administrative edits to TOC.

07/19/24 - Removed reference to a Quick Reference Guide in Services Requiring Prior Authorization and updated DME form link.

01/01/25 - Updated Concurrent Reviews and Expedited Coverage Authorizations section; administrative edits.

04/01/25 - Administrative updates to the Peer-to-Peer Reconsideration section; administrative edits.

04/04/25 - Updated Initial Determinations section.

01/01/26 - Updated to remove all Tufts Health Together MCO references.

04/07/26 - Removed statement that clinical peer reviewer will contact provider within one business day of request.

8Examples of Services Not Requiring PA

12Examples of Services Requiring PA (listed)

Typical expedited timeframe (hours)

Policy overview

Tufts Health Public Plans' Utilization Management Guidelines describe the structure and purpose of the UM program and how requests for coverage are evaluated for medical necessity, appropriateness, and efficiency. The Guidelines explain use of the Tufts Health Public Plans Medical Necessity Guidelines (MNGs) (and selected commercially purchased criteria such as InterQual) to guide determinations, and note that MNGs are developed by the Medical Policy Department and applied to select medical and behavioral health services and supplies.

The UM Program performs the core UM functions of prospective, concurrent, and retrospective review. Prospective and concurrent review are used for inpatient admissions, certain outpatient and behavioral health services, skilled nursing facility and post-acute services, rehabilitation, home care, surgical procedures, medical technology, pharmaceuticals, some DME, and targeted outpatient services; the UM team may also perform discharge planning and quality measurement and improvement. Tufts Health Public Plans reserves the right to conduct retrospective review of services provided to members.

The Guidelines apply across Tufts Health Public Plans products, including Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, and Tufts Health One Care, with product-specific details (for example, initial determination and urgent timeframes, and Evolent oversight) described in the chapter and product-specific subchapters. The chapter also covers prior authorization requirements and processes (initial, concurrent, expedited), continuity of care and transition rules, discharge planning requirements, appeals and peer-to-peer reconsideration procedures, and lists services that do and do not require prior authorization.

Policy metadata

Policy numberthpp-06-um-pm

PayerHarvard Pilgrim Health Care

Policy titleTufts Health Public Plans Utilization Management Guidelines

StatusCURRENT

Last review date2026-04-07

Effective date

Next review date

Document changes

2024-01-01revised

01/01/24 - Updated plan name to Tufts Health One Care.

2024-06-12revised

06/12/24 - Replaced 'National Imaging Associates, Inc./NIA' with 'Evolent'; administrative edits to TOC.

2024-07-19revised

07/19/24 - Removed reference to a Quick Reference Guide in Services Requiring Prior Authorization and updated DME form link.

Prior authorization — what does and does not require authorization

Services Not Requiring Prior Authorization

Prior authorization is not required for coverage of:

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title": "Services Not Requiring Prior Authorization",

Decision timeframes and review types

Continuity of care and transition rules

Discharge planning requirements for members experiencing or at risk for homelessness

Documentation Required

Discharge planning for homelessness

Providers must assess housing status within 24 hours of admission and begin discharge planning within 3 business days for members experiencing or at risk for homelessness. Document outreach to shelters, transportation arrangements, prescriptions provided, and items given to the member (e.g., weather-appropriate clothing/footwear, meals, health insurance information).

Assess housing status within 24 hours of admission
Invite and encourage the member's support team to participate in discharge planning
Arrange and provide paid transportation to emergency shelter when discharging to a shelter
Provide prescriptions and at least one week's worth of filled meds when clinically appropriate
Provide weather-appropriate clothing/footwear and a copy of health insurance information

Provider obligations and operational steps

Prior Authorization

Obtain prior authorization for listed services

Providers must obtain prior authorization for services listed under Services Requiring Prior Authorization (including out-of-network services, elective inpatient admissions, certain surgeries, DME, post-acute admissions, outpatient therapy beyond initial visits, certain drugs and behavioral health services). Failure to obtain required prior authorization may result in claims not being paid.

Documentation Required

Submit clinical updates for concurrent/continued stay reviews

If an inpatient stay extends beyond the initial authorization end date, the facility or attending physician must submit additional clinical information to substantiate the continued stay. Failure to submit required clinical updates, or submission of insufficient information, may lead to an adverse determination.

Referenced forms and external criteria

Referenced Forms / External Criteria / Programsmixed

Out-of-Network Coverage at In-Network Level of Benefits and Continuity of Care Prior Authorization Form	Form required to request out-of-network coverage at in-network level; PCP initiates for non-behavioral services
MassHealth Durable Medical Equipment and Medical Supplies General Prescription and Medical Necessity Review Form	Form referenced for DME authorizations
Tufts Health RITogether Durable Medical Equipment + Medical Supplies General Prescription and Medical Necessity Review Form	RITogether-specific DME form
Combined MassHealth MCO Medical Necessity Review Form for Enteral Nutrition Products (Special Formula)	Form for enteral nutrition PA for Tufts Health Together
Standardized Prior Authorization Request form	Form for enteral nutrition PA for Tufts Health RITogether
InterQual	Commercially purchased criteria used for some MNGs
Evolent (formerly NIA)	Prior authorization program vendor for high-tech imaging, cardiac/interventional and select procedures

Definitions

MNGsMedical Necessity Guidelines developed by the Medical Policy Department to determine medical necessity and appropriateness for coverage decisions.

InterQualCommercially purchased clinical criteria used for some medical necessity determinations.

EvolentVendor overseeing prior authorization programs for specified high-tech imaging and procedural reviews (formerly National Imaging Associates/NIA).

Administratively Necessary Day (AND)A billing rate hospitals may use when discharge is delayed due to lack of post-discharge placement (e.g., shelter bed unavailable).

Revision history

2024-01-01revised

01/01/24 - Updated plan name to Tufts Health One Care.

2024-06-12revised

06/12/24 - Replaced 'National Imaging Associates, Inc./NIA' with 'Evolent'; administrative edits to TOC.

2024-07-19revised

07/19/24 - Removed reference to a Quick Reference Guide in Services Requiring Prior Authorization and updated DME form link.

Policy Summary

Payerharvard pilgrim health care

Policythpp-06-um-pm

Policy CodePolicy thpp-06-um-pm

Change TypeAdministrative updates (no material clinical changes)

Effective Date

Next Review Date

Key ActionProviders must obtain prior authorization for services listed under 'Services Requiring Prior Authorization'; failure to obtain PA may result in claims not being paid.

SourceLink

On This Page

2025-01-01revised

01/01/25 - Updated Concurrent Reviews and Expedited Coverage Authorizations section; administrative edits.

2025-04-01revised

04/01/25 - Administrative updates to the Peer-to-Peer Reconsideration section; administrative edits.

2025-04-04revised

04/04/25 - Updated Initial Determinations section.

2026-01-01revised

01/01/26 - Updated to remove all Tufts Health Together MCO references.

2026-04-07revised

04/07/26 - Removed statement that clinical peer reviewer will contact provider within one business day of request.

Prior Authorization

Out-of-network PA initiation

For non-behavioral health out-of-network services, the member's PCP must initiate prior authorization using the Out-of-Network Coverage at In-Network Level of Benefits and Continuity of Care Prior Authorization Form. Tufts Health One Care members may also initiate the coverage request using that form.

Billing Rule

Administratively Necessary Day (AND) billing

If discharge is delayed because no emergency shelter bed is available, the hospital may bill the Administratively Necessary Day (AND) rate for each day the member remains in the hospital. Refer to the Inpatient Facility Payment Policy for additional details.

Step Therapy

Honor existing prior authorizations during transitions

Tufts Health Together and Tufts Health RITogether will honor existing prior authorizations from prior plans or providers for specified transition periods. Providers should confirm existing authorizations or obtain necessary authorizations to continue care during these transition windows.

Note

Request peer-to-peer reconsideration

Providers may request a peer-to-peer reconsideration for denials of inpatient admissions, outpatient services, or elective procedures. Tufts Health Direct and Tufts Health Together providers can submit an online Peer-to-Peer Request Form via the secure Provider portal or use the IVR (888-766-9818, option 4) to request a peer-to-peer review.

2025-01-01revised

01/01/25 - Updated Concurrent Reviews and Expedited Coverage Authorizations section; administrative edits.

2025-04-01revised

04/01/25 - Administrative updates to the Peer-to-Peer Reconsideration section; administrative edits.

2025-04-04revised

04/04/25 - Updated Initial Determinations section.

2026-01-01revised

01/01/26 - Updated to remove all Tufts Health Together MCO references.

2026-04-07revisedLatest

04/07/26 - Removed statement that clinical peer reviewer will contact provider within one business day of request.