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)
• Early Intervention ABA Service Request (H2019 only)Tools and Resources: Additional resources including a link to the Provider Search and the Mental Health Newsletter
• Find a provider
• Payment Policies
• Mental Health Self Service User Guide
• Provider Manuals
• Provider Education
• Intermediate Level of Care Admission Tool Training
• Mental Health Provider Credentialing Forms
• ICD-10 Resources
Please e-mail us your availability at firstname.lastname@example.org.
Designated Facilities Manual: Developed by the Tufts Health Plan Behavioral Health department to supply our Designated Facilities and their staff with details on the Designated Facility operating guidelines of Tufts Health Plan.
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.
• Autism, ABA, and Habilitative Therapy - Massachusetts Products
• Autism, ABA, and Habilitative Therapy - Rhode Island Products
• Custodial Care: Limitation of Inpatient Mental Health and Substance Use Treatment Benefits
• Extension of Outpatient Benefits
• Family Stabilization Treatment
• Nutrition Extension for Eating Disorders
• Outpatient Out of Plan Continuity of Care
• Outpatient Out of Plan Coverage of Mental Health/Substance Abuse Coverage Guidelines
• Outpatient Psychotherapy
• Psychological/Neuropsychological Testing
• Substance Use Community Residence Services - Rhode Island
• Transcranial Magnetic Stimulation (rTMS)
• Transcranial Magnetic Stimulation (rTMS) Prior Authorization Form- Commercial
• Urgent Mental Health Care Outside the Service Area
• VNA Home Care Criteria for Mental Health/Substance Use Services
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 acute stress disorder, ADHD, bipolar disorder, depression, eating disorders, panic disorder, schizophrenia and substance abuse.
• Acute Stress Disorder and Guideline Watch (APA)
• Attention Deficit/Hyperactivity Disorder (AAP)
• Bipolar Disorder and Guideline Watch (APA)
• Depression (APA)
• A Guide for Treating Depression in the Primary Care Setting
• Eating Disorders and Guideline Watch (APA)
• Panic Disorder (APA)
• Schizophrenia and Guideline Watch (APA)
• Substance Abuse and Guideline Watch (APA)
Educational Pamphlets: Contact the Mental Health Department to 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.
Under state and federal laws, benefits for mental health services and substance use disorder services must be comparable to benefits for medical/surgical services. This means that copayments, coinsurance and deductibles for mental health and substance use disorder services must be at the same level as those for medical/surgical services. Also, Tufts Health Plan’s review and authorization of mental health and substance use disorder services must be handled in a way that is comparable to the review and authorization of medical/surgical services.
Treatment for members who are covered under any of the mental health parity laws may still need to meet medical necessity guidelines. Therefore, under parity some plans may still require authorization.