[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288607-105":53,"doc-detail-288607-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","referrals-prior-authorizations-and-notifications","Referrals, Prior Authorizations and Notifications","","Guidance explains how Tufts Health Public Plans monitors referrals, prior authorizations, and inpatient notifications to support appropriate member care and cost efficiency. It details when valid PCP referrals are required for specialty services outside the Cambridge Health Alliance (CHA) ACO network, how referral numbers are issued and validated, and the rules on inquiry, adjustments, exclusions, and nonpayment for missing referrals. It also outlines prior authorization requirements for services, drugs, devices, supplies, and inpatient notification, including eligibility checks and submission timing.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/referrals-prior-authorizations-and-notifications/288607/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/referrals-prior-authorizations-and-notifications/288607.png","ImageObject",442,249,{"name":88,"@type":89},"Hazel","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-21","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"When is a referral required for specialty services?","Question",{"text":108,"@type":109},"Specialty services outside the Cambridge Health Alliance (CHA) ACO network require a valid referral on file with Tufts Health Public Plans. The member’s PCP must authorize the specialty care.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How are prior authorizations used and what happens if they are not obtained?",{"text":113,"@type":109},"Prior authorization is required for certain services, drugs, devices, and supplies based on medical necessity guidelines, InterQual criteria, or approved vendor management. Claims may not be paid if required prior authorization is not obtained, including related ancillary and supporting services.",{"name":115,"@type":106,"acceptedAnswer":116},"Does inpatient notification replace referral or prior authorization?",{"text":117,"@type":109},"No. Inpatient notification informs Tufts Health Public Plans of inpatient admissions, but it does not replace referral or prior authorization requirements for the service or procedure.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288607,1790031894,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":73,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":47,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":73},137441390410,"https://ap-avatar.wpscdn.com/avatar/2000252f4ab5702993?_k=1776741390130283984","Referrals, Prior Authorizations and Notifications  \nTo help ensure the quality of member care, Tufts Health Public Plans is responsible for monitoring authorization, medical appropriateness, and cost efficiency of services rendered. Refer to this chapter for information about:  \n•  Referrals  \n– Referral Inquiry  \n– Referral Adjustments  \n– Exclusions  \n•  Prior Authorizations  \n– Prior Authorization through Tufts Health Public Plans  \n– Prior Authorization through Approved Vendors  \n•  Inpatient Notification  \n– Notification Requirements  \n•  How to Submit Notification and Prior Authorization Requests  \n– Forms  \n•  Honoring Prior Authorizations from Previous Insurers  \n•  Telehealth/Telemedicine Requirements  \nReferrals (Tufts Health Together with Cambridge Health Alliance (CHA) only)  \nSpecialty services rendered outside of the Cambridge Health Alliance (CHA) ACO network require that a valid referral be on file with Tufts Health Public Plans. A referral verifies that the member’s primary care provider ( PCP) has authorized the specialty care.  \nThe member’s PCP must specify the number of visits and the type of specialty care required and follow their organization’s standard procedures to submit a referral. Upon approval, Tufts Health Public Plans issues a referral number which, in most cases, is valid in the Tufts Health Public Plans system for one year or until the approved number of visits is exhausted.  \nBefore providing care, specialists should check which members require a referral, or the status of an existing referral request, via the secure Provider portal. Specialists can also determine whether to request a referral by calling Provider Services at 888-257-1985. Tufts Health Public Plans will not pay for specialist visits that do not have a PCP referral when a referral is required. Members cannot be billed for these services.  \nReferral Inquiry  \nProviders may check the status of an existing referral by using the Referrals & Authorizations function via the secure Provider portal. Once submitted, it can take up to 24 hours for referral status to display.  \nReferral Adjustments  \nTo request an adjustment to a referral that is already in the Tufts Health Public Plans system, the PCP must contact Provider Services at 888-257-1985. Tufts Health Public Plans cannot adjust referrals based on the specialist’s request. If the specialist would like to request an adjustment to a referral, the specialist should follow up directly with the member’s PCP.  \nExclusions  \nTufts Health Together members do not require a PCP referral for services designated by MassHealth as exceptions to referral requirements as communicated and/or referenced in All Provider Bulletin 409.  \nPrior Authorizations  \nPrior authorization (prior approval) is required for certain services, drugs, devices , and supplies based on Tufts Health Public Plans medical necessity guidelines (MNGs) , InterQual® criteria, or as managed by an approved vendor. Any request for services provided by out-of-network (OON) providers requires prior authorization. Providers rendering services to members may not have claims paid if they fail to obtain required prior authorization, and claims for any related ancillary and supporting services may also deny.  \nUse the Prior authorizations page on our provider website to navigate to resources to support the prior authorization process , including MNGs. While MNGs are available on the website, you may also request printed copies by calling the Provider Service Center. Refer also to the Utilization Management Guidelines and the Behavioral Health chapters of this Provider Manual for additional information.  \nPrior Authorizations through Tufts Health Public Plans  \nAs a condition of payment, the ordering and treating provider must obtain approval for authorization requests. Refer to the appropriate MNG or Medical Drug MNG for prior authorization requirements. Authorization requests must include documentation of medical necessity for servi","cbCaijBp8qhGkn9n","https://ap.wps.com/l/cbCaijBp8qhGkn9n","pdf",183950,"English","# Referrals, Prior Authorizations and Notifications\n## Referrals\n## Prior Authorizations\n## Inpatient Notification","[{\"question\":\"When is a referral required for specialty services?\",\"answer\":\"Specialty services outside the Cambridge Health Alliance (CHA) ACO network require a valid referral on file with Tufts Health Public Plans. The member’s PCP must authorize the specialty care.\"},{\"question\":\"How are prior authorizations used and what happens if they are not obtained?\",\"answer\":\"Prior authorization is required for certain services, drugs, devices, and supplies based on medical necessity guidelines, InterQual criteria, or approved vendor management. Claims may not be paid if required prior authorization is not obtained, including related ancillary and supporting services.\"},{\"question\":\"Does inpatient notification replace referral or prior authorization?\",\"answer\":\"No. Inpatient notification informs Tufts Health Public Plans of inpatient admissions, but it does not replace referral or prior authorization requirements for the service or procedure.\"}]","Referrals, Prior Authorizations and Notifications | PDF",1789633691]