Mental Health Authorization Requirements for Senior Products by ntx18253

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									   Mental Health Authorization Requirements for
   Senior Products


The following grid is intended to clarify when authorization requirements apply depending on the member’s product.

                                                                                                 Intensive                                             Claims
                                      Outpatient Psychological/           Outpatient
                                                                                             Outpatient/Partial       Inpatient Treatment           Address/Filing
                Product                 Neuropsychological                Treatment                                                                                               Notes
                                                                                             Hospital Treatment                                        Limits
                                               Testing

 Tufts Medicare Complement (TMC)      Coverage for Medicare            Coverage for          Facility must be         Hospital must be             Tufts Health Plan         Medicare is the
                                      participating providers only     Medicare              Medicare participating   Medicare participating       HMO                       primary
                                                                       participating                                                               P.O. Box 9163             insurance
                                      A Psychological/                 providers only        Contact the Mental       Contact the Mental           Watertown, MA
                                      Neuropsychological Testing                             Health Department at     Health Department at         02471                     All providers
                                      Request Form must be             Contact the           800-208-9565             800-208-9565                                           must be
                                      submitted to the Mental Health   Mental Health                                                               Within 90 days of         Medicare
                                      Department and reviewed prior    Department for                                 Preregistration not          Medicare EOB              participating
                                      to services rendered             authorization                                  required
                                                                       (800) 208-9565
                                      Forms are available at
                                      tuftshealthplan.com/providers



 Medicare Complement Plan (MCP)       Coverage for Medicare            Coverage for          Facility must be         Hospital must be             Tufts Health Plan         Medicare is the
                                      participating providers only     Medicare              Medicare participating   Medicare participating       HMO                       primary
                                                                       participating                                                               P.O. Box 9163             insurance
                                      A Psychological/                 providers only        Contact the Mental       Contact the Mental           Watertown, MA
                                      Neuropsychological Testing                             Health Department at     Health Department at         02471                     All providers
                                      Request Form must be             Contact the           800-208-9565             800-208-9565                                           must be
                                      submitted to the Mental Health   Mental Health                                                               Within 90 days of         Medicare
                                      Department and reviewed prior    Department for                                 Preregistration not          Medicare EOB              participating
                                      to services rendered             authorization                                  required
                                                                       (800) 208-9565
                                      Forms are available at
                                      tuftshealthplan.com/providers




Originated 11/2006, Revised 11/2009                                                 1 of 2                                            Tufts Health Plan - Mental Health Authorization Requirements
                                                                                                             Intensive                                               Claims
                                            Outpatient Psychological/            Outpatient
                                                                                                         Outpatient/Partial         Inpatient Treatment           Address/Filing
                 Product                      Neuropsychological                 Treatment                                                                                                      Notes
                                                                                                         Hospital Treatment                                          Limits
                                                     Testing

 Tufts Health Plan Medicare Preferred      Approval is required. Contact     Prior authorization         The member is generally    The member is generally      Tufts Medicare            .
 (HMO)                                     the member’s PCP for              is required from the        assigned to a              assigned to a                Preferred
                                           authorization                     member’s PCP                Designated Facility (DF)   Designated Facility (DF)     P.O. Box 9183
                                                                                                                                                                 Watertown, MA
                                                                                                         Contact the Mental         Contact the Mental           02471
                                                                                                         Health Department at       Health Department at
                                                                                                         800-208-9565               800-208-9565                 Within 60 days of
                                                                                                                                                                 the date of service
                                                                                                                                    All inpatient admissions
                                                                                                                                    must be preregistered

                                                                                                                                    Contact the
                                                                                                                                    Precertification
                                                                                                                                    Department at
                                                                                                                                    800-672-1515


 Tufts Health Plan Medicare Preferred      Coverage for Medicare             Coverage for                Facility must be           Hospital must be             Tufts Medicare
 (PPO)                                     participating providers only      Medicare                    Medicare participating     Medicare participating       Preferred
                                                                             participating                                                                       P.O. Box 9183
                                           Authorization is not required     providers only              Contact the Mental         Contact the Mental           Watertown, MA
                                                                                                         Health Department at       Health Department at         02471
                                                                             Authorization is not        800-208-9565               800-208-9565
                                                                             required                                                                            Within 60 days of
                                                                                                                                    All inpatient admissions     the date of service
                                                                                                                                    must be preregistered

                                                                                                                                    Contact the
                                                                                                                                    Precertification
                                                                                                                                    Department at
                                                                                                                                    800-672-1515


 Medicare Private Fee-For-Service          Coverage for Medicare             Coverage for                Facility must be           Hospital must be             Tufts Medicare
 (PFFS)                                    participating providers only      Medicare                    Medicare participating     Medicare participating       Preferred
                                                                             participating                                                                       P.O. Box 9183
                                           Authorization is not required     providers only              Contact the Mental         Contact the Mental           Watertown, MA
                                                                                                         Health Department at       Health Department at         02471
                                                                             Authorization is not        800-208-9565               800-208-9565
                                                                             required                                                                            Within 60 days of
                                                                                                                                    All inpatient admissions     the date of service
                                                                                                                                    must be preregistered

                                                                                                                                    Contact the
                                                                                                                                    Precertification
                                                                                                                                    Department at
                                                                                                                                    800-672-1515

  The information contained in the document is a guide.
  For the most complete information, contact the Mental Health Department at 800-208-9565 or check the member’s benefits at tuftshealthplan.com.


 11/2006, Revised Revised
Originated 11/2006, 11/2009 10/2009                                                             2
                                                                                           2 of 2 of 2                                              Tufts Health Plan Mental Health Authorization Requirements
                                                                                                                                                   Tufts Health Plan - -Mental Health Authorization Requirements

								
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