Currentharvard pilgrim health carePolicy N/A

Behavioral health prior authorization and notification requirements

Defines prior authorization (PA), notification, and medical necessity review processes for inpatient, diversionary (24-hour and non-24-hour), and outpatient behavioral health services for Tufts Health Together and Tufts Health Direct providers.

Policy Summary

Payerharvard pilgrim health care

PolicyBehavioral health prior authorization and notification requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIn-network providers must call or fax THP for prior authorization, notification, or medical necessity review as required by the service-specific charts.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

fax 888-977-0776 / call 888-257-1985Provider contact

1 dayPHP notification

30–42 daysICC initial window

90 daysResidential Rehab billing

rTMS, In‑Home TherapyServices needing PA

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Service Coverage and Authorization Rules

Coverage stance for outpatient behavioral health services

Covered when service-specific rules below are met; PA/notification requirements vary by service and product.

Routine outpatient therapies: Individual, group, family therapy; medication visits; DBT; case consultation; psychiatric consultation on inpatient medical unit; inpatient–outpatient bridge visits — are covered benefits and, per this policy excerpt, do not require prior authorization or notification for admission (PA/Notification = N/A).

See Medical Necessity Guidelines: Outpatient Psychotherapy where referenced.

Psychological/Neuropsychological Testing: Psychological and neuropsychological testing is a covered assessment when ordered; most treatment facilities have an all-inclusive per diem that covers testing during inpatient or acute treatment, and Tufts does not reimburse individual providers for such inpatient testing; outpatient testing uses a supplemental fax form for PA when applicable.

Refer to Medical Necessity Guidelines: Neuropsychological and Psychological Testing and Assessment. Continued authorization processes are N/A for most outpatient testing.

Assessment for Safe and Appropriate Placement (ASAP): ASAP evaluations are covered but require prior authorization under MGL 119 Sec. 33B; provider coordinates with DCF and calls THPP for medical necessity review.

This is an evaluation, not a level of care.

Applied Behavioral Analysis (ABA) and EIBI: ABA therapy for Autism Spectrum Disorder is a covered benefit that requires prior authorization: submit the Autism Spectrum Disorder Services PA Request Form and Comprehensive Diagnostic Assessment; include testing documenting ASD diagnosis and copy of IEP when applicable. Early Intensive Behavioral Intervention (EIBI) is referenced under medical necessity guidelines; PA status for EIBI is noted as N/A in this excerpt.

Continued authorization for ABA is via fax of the PA request form.

Opioid Replacement and Ambulatory Detoxification: Opioid replacement therapy (methadone, buprenorphine, or other FDA-approved medications) and Ambulatory Detoxification (Level II.d) are covered services; they must conform to FDA and DEA regulatory requirements and reference Behavioral Health performance specifications. Per this excerpt, PA/notification for admission is listed as N/A.

Refer to Medical Necessity Guidelines: Behavioral Health-Opioid Treatment Services and Ambulatory Detox Performance Specifications.

CBHI / ICC / FS&T coverage and authorization criteria

Coverage and authorization specifics for CBHI/BHCA programs and paired FS&T/ICC services.

Family Support & Training (FS&T): FS&T is a covered benefit for Tufts Health Together members under age 21 and for Tufts Health Direct members under age 19. When FS&T is provided in conjunction with Intensive Care Coordination (ICC), initial notification is required (first 30–42 days depending on product) and ICC handles notification by faxing the CSA notification form; if FS&T is provided with In-Home Therapy (IHT) or outpatient as the hub, no notification, PA, or medical necessity review is required.

When provided with ICC, FS&T is included in the ICC day rate and ICC requests authorization for payment at time of ICC medical necessity review.

Intensive Care Coordination (ICC): ICC is a covered targeted case management service for individuals with Serious Emotional Disturbance. Notification is required for the initial period (document references 30–42 days depending on product); medical necessity review is required after the initial notification period (days 30+ or 43+ as specified). Providers must fax the CSA notification form for initial notification and call THPP for medical necessity review; continued authorization requires faxing the care plan and safety plan and calling THPP.

Program defined as targeted case management for Serious Emotional Disturbance; processes vary by Tufts product (Together vs Direct).

Service-specific coverage and authorization rules

Service-specific authorization and documentation rules; examples reflect the policy statements below.

FS&T when provided with ICC: FS&T provided with ICC is a covered benefit for eligible youth and is included in the ICC day rate; ICC requests authorization/payment at time of ICC medical necessity review and handles initial notification via CSA form faxing.

Initial notification windows: first 30–42 days depending on product.

ICC admission/notification: ICC requires initial notification (first 30–42 days depending on product) via faxed CSA notification form; medical necessity review is required after the initial notification period (days 30+ or 43+ as specified). Continued authorization requires faxing care and safety plans and calling THPP.

Provider calls THPP for medical necessity reviews.

In-Home Therapy (IHT) and In-Home Behavioral Services (IHBS): These in-home services are covered for youth; for some products prior authorization is required for admission and providers follow ICC/THPP processes for medical necessity review and continued authorization as specified by product guidelines.

Residential Rehabilitation Services (Level 3.1), Community Support Program for Homeless Individuals (CSP‑HI), Tenancy Preservation Program (TPP), and similar specialized community supports are covered benefits for Tufts Health Together members but are not covered for Tufts Health Direct members. For services that are covered, providers should follow the policy-specific notification and admission processes (for example, CSP‑HI/TPP require notification and a facility faxed notification form).

Tufts Health Plan does not reimburse individual providers for psychological or neuropsychological testing performed during an inpatient stay or at an acute treatment facility; such testing is generally included in the facility’s all‑inclusive per diem. Outpatient testing remains a covered benefit when ordered and requires submission of the Psychological and Neuropsychological Assessment supplemental form as specified in the Medical Necessity Guidelines.

Therapeutic Mentoring (TM) is a covered service that does not require prior authorization or notification for admission. Providers may bill directly for TM; there is no medical necessity review or continued authorization process described for this service in the document.

Electro‑Convulsive Therapy (ECT) is administered under anesthesia in facilities licensed by DMH and the policy references the Outpatient ECT Performance Specifications for clinical resources. The document indicates that PA/notification and medical necessity review processes for ECT are listed as N/A (no prior authorization, notification, or continued authorization requirements specified).

What Providers Must Do (PA, Notifications, Documentation)

Prior Authorization

Inpatient mental health — urgent admission notification and medical necessity review

Admitting facilities and ESPs do specific notifications for urgent inpatient psychiatric admissions; prior authorization is not required for urgent admissions but the facility must notify THPP and submit the Behavioral Health Notification Form – Psychiatric & Substance Use Treatment and the behavioral health assessment via the portal or by fax.

PA not required for urgent admission
Notify THPP within 72 hours of admission (defer to next business day if 72 hours falls on weekend/holiday)
Submit notification via portal or fax Behavioral Health Notification Form–Psychiatric & Substance Use Treatment + BH assessment
Facility calls THPP for continued authorization/med necessity review on the last covered day

Prior Authorization

Inpatient substance use disorder (Level 4) — notification timeframe and review

For inpatient substance use disorder (Level 4) admissions, prior authorization is not required at admission but the admitting facility must notify THPP and submit required documentation; concurrent medical necessity review is requested within the specified timeframe.

PA not required for admission to Level 4 inpatient SUD
Notify THPP within 7 days of admission
Submit notification via portal or fax Behavioral Health Notification Form–Psychiatric & Substance Use Treatment + BH assessment
Facility contacts THPP within 7 days to request concurrent medical necessity review on the last covered day
Facility calls THPP for continued authorization

Prior Authorization

24-hour diversionary services — urgent ED admission and notification process

24-hour diversionary services (community crisis stabilization, CBAT/ICBAT, ATS/3.7, and similar levels) do not require PA for urgent ED admissions; facilities/ESPs must notify THPP promptly and follow the portal/fax notification process and concurrent review timelines.

PA not required for urgent admission from ED to 24-hour diversionary services
ESP or admitting facility required to notify THPP within 72 hours of admission (72‑hour rule may defer to next business day if weekend/holiday)
Submit notification via portal or fax Behavioral Health Notification Form–Psychiatric & Substance Use Treatment + BH assessment
Admitting facility contacts THPP within 72 hours to request concurrent medical necessity review; facility calls THPP for continued authorization

Prior Authorization

Partial hospitalization (PHP) — notification timing and submission methods

Partial hospitalization (PHP) for in‑network providers does not require prior authorization at admission but requires notification within one calendar day; providers must use the portal or fax the Behavioral Health Notification Form and call THPP for concurrent/continued reviews.

For in-network providers, PA is not required at admission to PHP
Notification required within one calendar day after starting treatment
Submit notification via portal or fax Behavioral Health Notification Form–Psychiatric & Substance Use Treatment
Provider calls THPP on the last covered day to complete concurrent medical necessity review and for continued authorization

Note

Prior authorization and notification overview — processes by service and product

Prior authorization and notification requirements vary by level of care and product; use the portal or Behavioral Health Notification Form for admissions and follow specified timeframes for notifying THPP and requesting medical necessity reviews.

In-network providers: call 888-257-1985 or fax 888-977-0776 for PA/notification/medical necessity review as applicable
Out-of-network providers: request PA before initiating services
Use InterQual® (and ASAM where indicated) and THPP Medical Necessity Guidelines as resources
Follow the service‑specific notification timeframes (e.g., 72 hours for inpatient mental health and many diversionary services; 7 days for inpatient SUD Level 4; 1 calendar day for PHP)

Documentation Required

Observation / holding bed documentation and notification

Observation/holding bed admissions (up to 24 hours) do not require PA for urgent admission but the ESP/admitting facility must notify THPP, fax the ESP Notification Form and the behavioral health assessment, and call THPP after 48 hours if the stay continues to request a continuing stay medical necessity review.

PA not required for urgent admission to observation/holding beds
ESP and admitting facility must notify THPP
ESP faxes ESP Notification Form and the BH assessment to THPP
Admitting facility calls THPP after 48 hours of admission to request continuing stay medical necessity review
Facility calls THPP for continued authorization

Documentation Required

PHP documentation and notification submission

For Partial Hospitalization Program (PHP) documentation and notification, submit admission notification via the portal or fax the Behavioral Health Notification Form–Psychiatric & Substance Use Treatment within one calendar day; call THPP on the last covered day for concurrent/continued reviews.

Notification submission: portal or fax Behavioral Health Notification Form–Psychiatric & Substance Use Treatment within one calendar day of admission
Provider calls THPP on the last covered day to complete concurrent medical necessity review and for continued authorization

Prior Authorization

rTMS — prior authorization and required request form

rTMS requires prior authorization. Providers must fax the Repetitive Transcranial Magnetic Stimulation Request Form for initial PA and for continued authorization per THPP Medical Necessity Guidelines for rTMS.

Prior authorization required for rTMS
Fax the Repetitive Transcranial Magnetic Stimulation Request Form for initial and continued authorization
Refer to THPP Medical Necessity Guidelines: Transcranial Magnetic Stimulation (rTMS)

Level-of-Care Decision Criteria

Inpatient / 24-hour diversionary / Non-24-hour diversionary

Top-level admission, continued stay, and discharge expectations for inpatient and diversionary-level services.

General admission/notification expectations: Admitting facilities are required to notify THPP within specified timeframes: often within 72 hours for inpatient and many 24-hour diversionary services, within 7 days for some inpatient SUD (Level 4), and within one calendar day for Partial Hospitalization (PHP). For urgent inpatient admissions PA is not required but notification still applies.

Notification processes use portal submission or faxing the Behavioral Health Notification Form–Psychiatric & Substance Use Treatment along with the BH assessment.

Concurrent medical necessity review processes: Facilities/providers must contact THPP/THP on the last covered day to request concurrent medical necessity review for continued authorization for many inpatient and diversionary services; some enhanced Level 3.7 services require notification for days 1–14 and medical necessity review for days 15+.

Facility typically calls THPP to complete concurrent review; if 72 hours falls on weekend/holiday notification is deferred.

Intensive Care Coordination (ICC)

ICC admission, notification, and continued authorization rules (Tufts product-specific timing preserved).

ICC admission/notification: ICC provides targeted case management for individuals with Serious Emotional Disturbance; notification is required for the initial 42 days for Tufts Health Together (notification via faxed CSA Notification form) and medical necessity review is required for days 43 and beyond; providers call THPP for reviews.

Continued authorization process requires faxing care plan and safety plan, then calling THPP.

ICC continued stay: For continued authorization when required, provider faxes copy of the care plan and safety plan, then calls THPP to complete the medical necessity review for ongoing ICC services.

Timing and initial notification window vary by Tufts product (e.g., some products reference a 30-day initial window instead of 42 days).

Targeted Case Management / Intensive Care Coordination

Criteria for Targeted Case Management and ICC, including initial notification windows and continued authorization steps.

Initial notification requirement for ICC: Notification is required for an initial 30–42 day period depending on the product (Tufts Health Together vs Tufts Health Direct); provider faxes the CSA notification form to THPP for initial notification.

Product-specific guidance: Tufts Health Together references 42 days; Tufts Health Direct references 30 days.

Continued authorization for ICC: Medical necessity review is required after the initial notification period; provider must fax the care plan and safety plan and call THPP to request continued authorization/medical necessity review.

Providers follow the THPP Medical Necessity Guidelines for targeted case management/ICC.

Specific Treatment Programs and Modalities

Acute Treatment Services (Level 3.7)

Criteria and administrative timing for Enhanced Level 3.7 acute treatment services.

Enhanced Level 3.7 (Acute Treatment Services): Enhanced Level 3.7 services (EATS, DDART and other ATS for substance use disorders) require notification within 72 hours of admission and specifically require notification for days 1–14; medical necessity review is required for days 15 and beyond, with the facility calling THPP on the last covered day to complete concurrent review.

PA/Notification/MNG resources reference InterQual and ASAM Criteria Navigator; facility uses portal submission or faxing the Behavioral Health Notification Form.

Opioid Replacement Therapy / Ambulatory Detoxification

Authorization and regulatory requirements for outpatient opioid replacement and ambulatory detox services.

Opioid Replacement Therapy: Opioid replacement therapy (medically monitored administration of methadone, buprenorphine, or other FDA-approved medications) is a covered service and must conform to FDA and DEA requirements. Per this excerpt, PA/notification for admission is listed as N/A.

Refer to Medical Necessity Guidelines: Behavioral Health-Opioid Treatment Services (Methadone Maintenance) Level of Care.

Ambulatory Detoxification (Level II.d): Ambulatory Detoxification provides outpatient services for members experiencing serious episodes of substance use; PA/notification for admission is listed as N/A in this excerpt and providers follow Behavioral Health Ambulatory Detox Performance Specifications.

Continued authorization processes are listed as N/A in this portion of the document.

ECT and rTMS

Authorization and documentation expectations for ECT and rTMS.

Electro-Convulsive Therapy (ECT): ECT is administered under anesthesia in facilities licensed by DMH and is a covered therapeutic service. In this excerpt PA/notification/medical necessity review and continued authorization processes are listed as N/A; refer to Outpatient ECT Performance Specifications for clinical guidance.

Facility licensure by DMH is required to provide ECT.

Repetitive Transcranial Magnetic Stimulation (rTMS): rTMS is a covered, non-invasive neurostimulation service that requires prior authorization. Providers must fax the Repetitive Transcranial Magnetic Stimulation Request Form for initial and continued authorization per the policy.

See THPP Medical Necessity Guidelines: Transcranial Magnetic Stimulation (rTMS) for detailed criteria.

Time and Unit Limits for Services

inv-50: Recovery Support Navigators and Residential Rehabilitation billing allowance — 90 days / 360 units as applicable

Allowed billing windowProviders may bill Residential Rehabilitation Services (Level 3.1) and Recovery Support Navigators for up to 90 days (or up to 360 units) upon timely notification

Notification requirementFacility must fax the Residential Rehabilitation form or Recovery Support Navigator form to THPP within one week of admission to enable billing up to the allowed limit

Continued authorizationFacility must fax First Clinical Review form within one week prior to or after end date of initial authorization and call THPP to complete medical necessity review for continued authorization

inv-51: Peer Recovery Coach billing allowance and review timeline — providers may bill up to 180 days; review required for days 180+

Allowed billing windowProviders may bill Peer Recovery Coach services for up to 180 days upon timely notification

Notification timing and processFacility notifies THPP by faxing the Peer Recovery Notification form within 14 days of start of service

Review for extended servicesMedical necessity review is required for days 180 and beyond; continued authorization review occurs within one week prior to or after the end date of the initial 180-day treatment period

inv-52: No explicit numeric visit limits specified for routine outpatient services in this excerpt — outpatient therapy, family consult, medication visits, diagnostic evals

Outpatient therapy (individual/group) limitsNo explicit numeric visit limits specified in this excerpt; PA/Notification = N/A for most outpatient psychotherapy services

Family consultationNo numeric visit limit stated; family consultation lists PA/Notification = N/A and may be billed with outpatient therapy visits

Medication visits and psychiatric consultationNo numeric visit limits specified; Medication Visits and Psychiatric Consultation list PA/Notification = N/A

Diagnostic evaluationsDiagnostic Evaluation is listed as an evaluation (not a level of care) with PA/Notification = N/A and no numeric visit limits specified

inv-53: No explicit visit limits stated in this portion of the document — placeholder summary

General statementNo explicit visit limits are stated in the referenced portions of the document for many services (visit limits are either not listed or are handled via medical necessity/authorization processes)

ICC and FS&TICC notification and continued authorization periods are specified (initial notification period then medical necessity review) rather than fixed visit counts

Services without numeric limitsSeveral service definitions and PA/notification rules describe processes but do not provide numeric visit caps in this excerpt

Definitions and Background

Behavioral health services are delivered across multiple settings and intensities: inpatient 24‑hour services for acute mental health or substance use disorders; 24‑hour and non‑24‑hour diversionary services (such as community crisis stabilization, Community‑Based Acute Treatment, residential rehabilitation, CSP‑HI/TPP, and Partial Hospitalization) that serve as alternatives to inpatient care; and outpatient therapies and programs for ongoing treatment and recovery. Diversionary programs support stabilization and transition back to community functioning, while outpatient services provide diagnostic evaluation, psychotherapy, medication visits, case consultation, and specialty treatments. Notification, prior authorization, and concurrent medical necessity review requirements differ by level of care and service type and are specified in the policy for each service category.

inv-34: Diversionary Services definition — mental health or SUD services as alternatives to inpatient

DefinitionDiversionary Services are mental health or substance use disorder services provided as an alternative to inpatient services to support community functioning or transition from acute care

SettingsIncludes both 24-hour facilities and non-24-hour settings (e.g., crisis stabilization, residential rehabilitation, partial hospitalization)

PurposeUsed to engage members returning to the community after 24-hour acute placements or to provide intensive support to maintain community functioning

inv-35: Partial Hospitalization (PHP) definition — short-term day programming 5-7 days/week

DefinitionPartial Hospitalization (PHP) is short-term day mental health programming available 5 to 7 days a week as an alternative to inpatient services

Admission/authorization stanceFor in-network providers PA is not required for admission; notification is required one calendar day after starting treatment

Continued authorization processProvider calls THPP on the last covered day to complete concurrent medical necessity review

inv-36: PACT definition — Program of Assertive Community Treatment description

DefinitionProgram of Assertive Community Treatment (PACT) is a multidisciplinary team approach providing acute, active, ongoing, long-term community-based psychiatric treatment, assertive outreach, rehabilitation, and support

Coverage notePACT is a covered benefit for Tufts Health Together members; providers bill directly and PA/notification is listed as N/A

Service characteristicsEmphasizes assertive outreach, rehabilitation, and long-term community-based support delivered by a multidisciplinary team

inv-37: Psychological/Neuropsychological Testing definition — standardized instruments and purposes

DefinitionPsychological/Neuropsychological Testing uses standardized test instruments to assess cognitive, emotional, neuropsychological, verbal, and defensive functioning

Inpatient reimbursement noteMost treatment facilities have an all-inclusive per diem that covers needed testing; Tufts Health Plan does not reimburse individual providers for such testing done during an inpatient stay or acute treatment

Authorization process for outpatient testingOutpatient testing uses a Psychological and Neuropsychological Assessment supplemental form (fax) for medical necessity documentation

inv-38: Opioid Replacement Therapy definition — FDA-approved medications and monitored administration

DefinitionOpioid Replacement Therapy is the medically monitored administration of FDA-approved medications (e.g., methadone, buprenorphine) in conformance with FDA and DEA requirements

Regulatory requirementServices must conform to FDA and Drug Enforcement Administration (DEA) regulations; referenced Medical Necessity Guidelines: Behavioral Health-Opioid Treatment Services

PA/notification stancePA/Notification for admission is listed as N/A in this excerpt

inv-39: Intensive Care Coordination (ICC) definition — targeted case management for SED

DefinitionIntensive Care Coordination (ICC) provides targeted case management services to individuals with Serious Emotional Disturbance, including those with co-occurring conditions

Notification and review timingNotification is required for the initial period (document references first 30–42 days depending on product); medical necessity review is required for days 43+ (Tufts Health Together) and continued authorization requires faxing care and safety plans then calling THPP

ProcessProvider faxes a CSA Notification form for initial notification and calls THPP for medical necessity review and continued authorization

inv-40: Therapeutic Mentoring (TM) definition — structured one-to-one mentoring

DefinitionTherapeutic Mentoring (TM) provides a structured, one-to-one mentoring relationship between a therapeutic mentor and a child or adolescent to address daily living, social, and communication needs

PA/notification stanceNo prior authorization or notification is required; providers may bill directly for the service

Authorization/continued reviewNo continued authorization process is required; PA/Notification/Medical Necessity Review listed as N/A

inv-41: Electro-Convulsive Therapy (ECT) definition — therapeutic induction of seizure activity under anesthesia

DefinitionElectro-Convulsive Therapy (ECT) is a therapeutic procedure that induces seizure activity under anesthesia and is administered in facilities licensed by the DMH

Performance specificationsRefer to Outpatient ECT Performance Specifications as noted in the document

PA/notification stancePA/Notification/Medical Necessity Review and continued authorization are listed as N/A for ECT in this excerpt

inv-42: Repetitive Transcranial Magnetic Stimulation (rTMS) definition — non-invasive neurostimulation description

DefinitionRepetitive Transcranial Magnetic Stimulation (rTMS) is a non-invasive neurostimulation technique applying rapidly changing magnetic fields to the scalp through a coil

PA requirementrTMS requires prior authorization; providers must fax the Repetitive Transcranial Magnetic Stimulation Request Form for initial and continued authorization

GuidanceRefer to THPP Medical Necessity Guidelines: Transcranial Magnetic Stimulation (rTMS) for detailed criteria

OpenPayer

Behavioral health prior authorization and notification requirements

Service Coverage and Authorization Rules

What Providers Must Do (PA, Notifications, Documentation)

Level-of-Care Decision Criteria

Applied Behavioral Analysis Authorization Rules

Specific Treatment Programs and Modalities

Time and Unit Limits for Services

Definitions and Background