Mental Health & Substance Abuse
Mental Health Authorization Requirements: Two grids that detail the mental health authorization requirements for Commercial and Senior products.Outpatient Treatment Authorizations: Information on how to obtain and keep track of patient authorizations. Details the different methods for obtaining authorizations, including using the secure provider website and IVR.
Who gets the authorizations?
It is the treating provider’s responsibility to obtain the necessary treatment authorization for outpatient mental health and substance abuse services for both initial and additional visits.
Providers must obtain an initial authorization for patients who are new to the practice. If the patient is not new but the previous authorization is more than 12 months old and has therefore expired, providers must obtain an initial authorization.
Authorizations for Additional Visits
Providers must request a Mental Health Care Services Request (MHCSR) for patients who are continuing with their treatment and have exhausted all authorized visits within the 12 month date range.
Requesting Initial and Additional Authorizations
Providers can obtain authorizations for both initial and additional visits by:
• Logging in to the secure provider website to request a Mental Health Care Services Request (MHCSR). Refer to the Mental Health Self Service User Guide for assistance with submitting initial and additional authorizations.
• Using the Interactive Voice Response (IVR) system by calling 800-208-9565. For additional visits, refer to the Guide for Completing Mental Health Care Services Request Using IVR
Note: Authorizations can be backdated up to 30 calendar days.
Providers will receive a new authorization number each time an authorization request is approved. If the authorization is requested online, the authorization number will begin with a K. If the authorization is requested via the IVR, the authorization number will begin with a V. Initial authorizations given over the phone by a Mental Health Coordinator will begin with an R.
How long are authorizations good for?
Authorizations are valid for 12 months or until the number of visits on the authorization are exhausted. This means that authorized visits “carry over” into a new calendar or plan year. Authorizations do not override the member’s benefit limit.
Authorizations and Mental Health Parity
Authorizations must be obtained for members with Mental Health Parity. Outpatient mental health services must be medically necessary. View the Outpatient Psychotherapy Medical Necessity Guidelines.
Psychological and Neuropsychological Testing: Information on psychological and neuropsychological testing requirements including the testing request formInpatient Mental Health & Substance Abuse: Information specific to the Inpatient Mental Health program, including the After-Care Review Form.Autism/ABA: Resources and information regarding the coverage of Applied Behavioral Analysis and Autism
• Autism, ABA and Habilitative Therapy Medical Necessity Guidelines
• Autism Professional Payment Policy
• ABA Initial Services Request—Assessment and Treatment Planning (H0031) ONLY
• ABA Autism Service Request (Initial and Continued)Tools and Resources: Additional resources including a link to the Provider Search and the Mental Health Newsletter
• Find a provider
• Payment Policies
• 2013 Behavioral Health Newsletter
• Mental Health Self Service User Guide
• Provider Manuals
• Provider Education
• Mental Health Provider Credentialing Forms
Please e-mail us your availability at email@example.com.
Providers should confirm member benefits prior to rendering services. Members are covered as described in their benefit document. Providers can obtain specific benefit information by:Outpatient Care
Outpatient coverage includes mental health and substance abuse treatment, medication, evaluation and monitoring. The Mental Health and Substance Abuse provider is responsible for obtaining the necessary authorization. PPO members do not require authorization. For more information, refer to the Outpatient Mental Health/Substance Abuse Payment Policy.Inpatient and Intermediate Care
Depending on the member’s plan type and structure, the member may be assigned to a specific Designated Facility (DF) or be required to go to one of Tufts Health Plan’s DFs. DF assignment is based on the member’s PCP selection. Depending on the Tufts Health Plan DF, payment for Mental Health and Substance Abuse services can either be capitated or fee-for-service. A capitated DF is responsible for managing the care of members for whom they have received capitated payment. All Tufts Health Plan Designated Facilities are in Massachusetts.
Facility Assignment by Plan Type
• HMO members must seek treatment at their assigned DF.
• If a member is not assigned to a DF, the PCP arranges the member’s care
• EPO members can seek treatment at any Tufts Health Plan DF.
• POS members have two levels of benefits:
• Authorized: services rendered at any Tufts Health Plan DF
• Unauthorized: services rendered at any facility outside of the Tufts Health Plan DF system
(contracting AND non-contracting)
• PPO members also have two levels of benefits:
• In-network: services rendered at any Tufts Health Plan contracted facility
• Out-of-network: services rendered at any non-contracted facility
• CareLinkSM members’ coverage varies by plan design and depends on which entity is the
primary administrator – check the member’s benefit.
For more information, refer to the Inpatient Mental Health/Substance Abuse Payment Policy.
* Some employer groups have chosen another company to manage and administer the Mental Health and Substance Abuse benefit. If the member is unsure, please have them check their Tufts Health Plan identification card or contact Tufts Health Plan Mental Health Department at 1-800-208-9565.
Medical Necessity Guidelines: Links to the Medical Necessity Guidelines for Psychological/Neuropsychological Testing, Autism, etc.
• Psychological/Neuropsychological Testing
• Outpatient Psychotherapy
• Autism, ABA, and Habilitative Therapy - Massachusetts Products
• Autism, ABA, and Habilitative Therapy - Rhode Island Products
• Urgent Mental Health Care Outside the Service Area
• Outpatient Out-of-Plan Continuity of Care
• Nutrition Extension for Eating Disorders
• Family Stabilization Treatment
• Transcranial Magnetic Stimulation (rTMS)
• Transcranial Magnetic Stimulation (rTMS) Prior Authorization Form- Commercial
Click here to link to the Pharmacy page for medical necessity guidelines related to medications.Clinical Guidelines: Find clinical guidelines and links to resources for the treatment of ADHD, bipolar disorder, depression, eating disorders and substance abuse.Educational Pamphlets: Request these pamphlets for distribution in your office
The Parent/Professional Advocacy League (PPAL): Link to the website for PPAL, which is dedicated to improving the mental health and well-being of children and families through education and advocacy.
Treatment for members who are covered under any of the mental health parity laws must meet medical necessity guidelines. Therefore, authorization is required for those plan types that require it. The federal mental health parity provisions take precedence over state mental health parity laws.Federal Mental Health and Substance Abuse Parity Law
• The federal law requires all group health plans that offer coverage for mental health and substance abuse disorders to apply the same treatment and financial limits to those disorders as apply to medical benefits.
• Members enrolled in plans governed by federal mental health and substance abuse parity have no financial or service limits, however, the services provided must be medically necessary.
• The law applies to all members enrolled in Massachusetts and Rhode Island fully insured and self-insured group health plans with 51 or more employees. The law does not apply to members enrolled in a group health plan with 50 or fewer employees, or to members enrolled in individual plans. If a member is not enrolled in a plan governed by the federal mental health and substance abuse parity law, their plan may be subject to comparable state law provisions (see below).Massachusetts State Mental Health Parity Law
• The Massachusetts state mental health parity law mandates that coverage for biologically based mental disorders cannot have annual or lifetime dollar maximums or coverage limitations on the number of days/visits of service that are less than the limitations placed on coverage for the diagnosis and treatment of physical conditions.
• Members enrolled in plans governed by the Massachusetts mental health parity law are covered for unlimited medically necessary treatment of the specified biologically-based disorders.
• The law applies to all members enrolled in Massachusetts fully insured plans. The law does not apply to members who are enrolled in self-insured group plans, although self-insured groups may opt to implement its provisions voluntarily.
Rhode Island Mental Health and Substance Abuse Parity Law
• The Rhode Island mental health and substance abuse parity law mandates that insurers cover the diagnosis and treatment of mental health and substance abuse to the same degree as the diagnosis and treatment of physical conditions. Members covered under the Rhode Island mental and substance abuse parity law are covered for up to 30 medically necessary outpatient visits to treat mental health conditions per calendar year and 30 medically necessary outpatient visits to treat substance abuse disorders per calendar year.
• The law applies to members enrolled in Rhode Island fully insured plans. It does not apply to members who are enrolled in self-insured group plans, although self-insured groups may opt to implement its provisions voluntarily.