Referrals, Prior Authorizations and Notifications - - Referral Exclusions - Completing the Paper Referral Form - Electronic Referral Exclusions

Sep 17, 2026

Upload by Grenda

Comprehensive guidance covering referral management, prior authorization, and notification workflows for Tufts Medicare Preferred plans. Explains the PCP’s role in approving specialist services, coordination before care begins, and conditions under which referrals are and are not required. Details referral exclusions, requirements for completing paper referral forms, claim review and submission processes, and key electronic referral exceptions. Also outlines inpatient notification steps, submission channels, payment handling, and facility requirements for approved services.

LanguageEnglish

CategoryForms

FormatPDF

Pages12

Reading Time4 min

AccessFree to download

Referrals

Referral Exclusions

Completing the Paper Referral Form

Electronic Referral Exclusions

Out-of-Area Services

Referral Inquiry

Referral Adjustments

Prior Authorizations

Medical Coverage Prior Authorization Requests

Prescription Drugs Prior Authorization Requests

Pharmacy Plan Management Programs

Appeals and Grievances for Pharmacy Benefits

Organization Determinations

Benefit Exhaustions

Prior Authorization Lists

Notifications

Inpatient Notification Process

Inpatient Notification Requirements

Submission Channels

Payment

Medicare-Approved Facility Requirement

Referrals, Prior Authorizations and Notifications • Referrals – Referral Exclusions – Completing the Paper Referral Form – Electronic Referral Exclusions – Out-of-Area Services – Referral Inquiry – Referral Adjustments • Prior Authorizations – Medical Coverage Prior Authorization Requests – Prescription Drugs Prior Authorization Requests – Pharmacy Plan Management Programs – Appeals and Grievances for Pharmacy Benefits – Organization Determinations – Benefit Exhaustions (Tufts Medicare Preferred HMO members) – Prior Authorization Lists • Notifications – Inpatient Notification Process – Inpatient Notification Requirements – Submission Channels – Payment – Medicare-Approved Facility Requirement Referrals A referral verifies that the member’s PCP has approved the member’s request to receive services from a specialist provider. It is the responsibility of the PCP to ensure that the member is directed to the appropriate specialist. Referrals should be coordinated prior to services being rendered. Referrals are not required for Tufts Medicare Preferred PPO members. To ensure that appropriate specialty care is provided for Tufts Medicare Preferred HMO and/or Tufts Health Plan SCO members, the PCP must initiate and coordinate the referral management process according to the following list: • The PCP may approve a referral to a specialist in or out of the Tufts Medicare Preferred HMO or Tufts Health Plan SCO networks, indicating the specific services and number of visits to be provided to the member, when: – The PCP decides that such a referral is medically necessary – The specialist agrees to a treatment plan and provides the PCP with all necessary clinical and administrative information on a regular basis – The health care services to be provided are consistent with the terms of the member’s plan benefits • Specialists must submit a summary report on a timely basis to the medical group following the member’s appointment. • Any questions or problems regarding referrals should be directed to Senior Products Member Services. • PCPs should not generate referrals for urgent/emergent services and should instead contact the Tufts Medicare Preferred HMO or Tufts Health Plan SCO care manager to notify of urgent/emergency care. Providers should contact Senior Products Provider Services at 800-279-9022 to identify the care manager assigned to the member. All PCP urgent/emergent admissions are reported to the group care manager on a daily basis on the Day of Admission report. • Tufts Health Plan is financially responsible for any nonurgent/nonemergent outpatient care authorized by Tufts Health Plan that is provided outside the network; if authorized by the medical group that provides services (rather than Tufts Health Plan), the care is the financial responsibility of the medical group. Referral Exclusions Tufts Health Plan does not require a PCP referral for the following services, including, but not limited to: • Ancillary care: – Laboratory services – Radiology services Note: Some radiology services require prior authorization. Please refer to the Imaging Services Payment Policy for more information. – Anesthesia services Note: Some anesthesia services require prior authorization. Please refer to the Anesthesia Services Payment Policy for more information. • Obstetric and gynecological care rendered by a contracting obstetrician, gynecologist, certified nurse midwife, or family practitioner: – Annual preventive gynecologic health examinations, including care deemed medically necessary by the practitioners listed above – Maternity care • Covered practitioner services provided in an inpatient setting (place-of-service 21) • Services rendered in emergency department (ED), qualified urgent care center, or limited services clinic (e.g. , MinuteClinics), including independent laboratory services ordered by these facilities Completing the Paper Referral Form

FAQs

When are referrals required for Tufts Medicare Preferred HMO and/or Tufts Health Plan SCO members?

Referrals are required to ensure appropriate specialty care. The PCP must initiate and coordinate the referral management process according to the policy requirements before services are rendered.

Which services are excluded from requiring a PCP referral?

Tufts Health Plan does not require a PCP referral for listed services such as certain ancillary care (with some radiology or anesthesia possibly needing prior authorization), specified obstetric and gynecological care, covered practitioner services in an inpatient setting, and services in emergency department or qualified urgent care/limited service clinics.

What happens if a paper referral form has required fields left blank?

The referral form is returned to the PCP requesting additional information. After receipt of a complete referral, the Tufts Health Plan Claims Department enters the referral into the system.

Sep 17, 2026

Upload by Grenda