Specialty Services Referral Requirement Payment Policy
This policy applies to Tufts Health Together (MassHealth), Tufts Health Forward (Commonwealth Care), and Tufts Health Extend members.
Tufts Health Plan – Network Health requires a primary care provider (PCP) referral for specialty services rendered after January 16, 2011, for members in certain provider systems. Providers can check which members require a referral, or the status of an existing referral request, through Network Health Connect or by calling Tufts Health Plan – Network Health at 888-257-1985. Providers can also look for "PCP referral required" on the member’s ID card.
The PCP referral requirement applies to members in certain provider systems seeking nonemergent specialty services, including professional services, outpatient hospital visits, surgical day care, and initial visits/evaluations for physical, occupational, or speech and hearing therapy.
Tufts Health Plan – Network Health does not require a PCP referral for the following services:
- Ancillary care:
- Obstetric and gynecological care rendered by a contracted 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
- Medically necessary evaluations and resultant health care services for acute or emergency gynecologic conditions
- Covered physician services provided in an inpatient setting (place-of-service = POS 21)
- Behavioral health services rendered by licensed, in-network behavioral health providers
- Services rendered at an emergency room, qualified urgent care center, or limited service clinic (e.g., MinuteClinics)
- Independent laboratory services ordered by an emergency room, qualified urgent care center, or limited service clinic
This policy will not change any existing authorization requirements. If a prior authorization is required, a referral is not. For additional services that require authorization, please refer to the medical and behavioral health benefit summary grids.
Billing and reimbursement
We will not pay for specialty services that do not have a PCP referral for members who need one. You cannot bill members for these services.
This policy applies to Tufts Health Together, Tufts Health Forward, and Tufts Health Extend plans and is incorporated by reference into Tufts Health Plan – Network Health's Provider Manual. Payment is based on member benefits and eligibility, medical necessity review, where applicable, and the Tufts Health Plan – Network Health provider agreement. Adherence to these guidelines by a provider does not guarantee payment. Tufts Health Plan – Network Health reserves the right to amend a payment policy at its discretion. 03284