We require prior authorization before you send someone to see one of our nonpreferred in-network or out-of-network providers, except for emergency, post-stabilization, and urgent care. To check which providers require prior authorization, see our Find a Doctor, Hospital, or Pharmacy tool.
We also require prior authorization for:
- Certain covered services (e.g., inpatient admissions, some types of surgery)
- Home health care
- Durable medical equipment
- Certain behavioral health services
- Certain medications
- Advanced radiology imaging services
To check if a service is covered and/or requires prior authorization, please see our medical and behavioral health benefit summary grids.
Please note: If you are a primary care provider, make sure the patient is in our records as part of your panel before rendering services. We require prior authorization for services rendered to a Tufts Health Plan – Network Health member who is not in your panel.
How to request prior authorization
For members of Tufts Health Together (MassHealth), Tufts Health Forward (Commonwealth Care), Tufts Health Extend, Tufts Health Direct (an individual and small-group plan), or Network Health Choice (an individual and small-group plan):
- Pharmacy services, including specialty pharmacy drugs — fax a completed medication request form to us at 617-673-0988 or call provider services at 888-257-1985
- Medical services — fax a completed prior authorization request to 888-415-9055 or call our medical management team at 888-257-1985
- Behavioral health services — fax a completed prior authorization request to 888-977-0776 or call our behavioral health team at 888-257-1985
- Advanced radiology imaging services — contact National Imaging Associates (NIA), an organization specializing in managing diagnostic services
For members of Tufts Health Unify (Medicare-Medicaid One Care for people ages 21 – 64):
To request other authorizations, please fill out the appropriate form and fax or mail it to us at:
Tufts Health Plan – Network Health
Attn: Medical Management
101 Station Landing, Fourth Floor
Medford, MA 02155
If an authorization request is urgent
For urgent authorization needs, please call us at 888-257-1985.
Please check eligibility on the date of service; approval depends on eligibility and other determining factors. We do not pay for services rendered to patients who were not Tufts Health Plan – Network Health members on the date of service.