Utilization management

Tufts Health Plan – Network Health established policies and procedures that govern our utilization management (UM) program. We base all UM decisions on appropriateness of care, availability of services, and your patients’ coverage. We do not reward providers, UM clinical staff, or consultants for denying care, and do not offer network providers, UM clinical staff, or consultants money or financial incentives to encourage less use of services. To request our utilization criteria for any of our services or to talk to a clinician about any UM denial decision, please call us at 888-257-1985.

Utilization management policies and procedures

Tufts Health Plan – Network Health established policies and procedures that govern our utilization management (UM) program. These policies and procedures address important service issues in delivering UM, including:

  • Decision timeliness
  • Internal data-gathering consistency
  • Decision-making accountability compared to our evidence-based UM criteria and guidelines
  • New technology access
  • Member and provider UM-process satisfaction

Department managers monitor compliance with these policies to ensure that they are consistently met. Specific cases are expedited based on a member's medical need or based on unique case-related circumstances.

Utilization review (UR) can also be referred to as utilization management (UM). UR/UM includes the evaluation of prior authorization requests for coverage by determining member eligibility, benefit coverage, and medical necessity of services for the requested level of care. We can receive prior authorization requests by fax, mail, or telephone. You are responsible for requesting prior authorization. There are a number of reasons we do not require prior authorization, including for conditions that a prudent layperson would consider life- or limb-threatening. You can learn more about our prior authorization policy in the Provider Manual

Appropriately licensed staff makes UM decisions. Qualified licensed health care professionals render or supervise all clinical-coverage review decisions. Staff members who are not qualified health care professionals may collect the clinical documentation for prior authorization and concurrent review under the supervision of appropriately licensed health professionals and may also have the authority to approve (but not to deny) coverage for services for which there are criteria/guidelines. 

Only qualified, licensed physicians with the appropriate clinical expertise make decisions to deny coverage.Tufts Health Plan – Network Health established a process to consult with board-certified specialists in appropriate specialty areas when indicated. 

We are available to answer questions about our UM process, including any UM denial decisions, and provide clinical access 24 hours a day, seven days a week for inbound and outbound calls, and other types of communication.

We can receive inbound communications about UM issues after normal business hours. On-call staff handles after-hours coverage for medical UM issues. A vendor provides after-hours coverage for behavioral health UM issues after 5 p.m. Monday through Friday. This behavioral health on-call service provides coverage to triage service requests as necessary from members and/or providers, for urgent service authorizations, and pharmacy-related inquiries.

Call us at 888-257-1985 for UM services and questions.


Request to review utilization management criteria

 

Tufts Health Plan – Network Health utilizes criteria to determine the appropriateness of services requested. You may request to review the criteria prior to a utilization management (UM) decision, or in the event of a denial, in the following ways:

  • Via telephone: A clinician will read the criteria over the telephone to you.
  • Mail/Fax: We will mail a paper copy to you of the criteria we utilized to make the decision.
  • On-site review: You may request an on-site review of the criteria. If our clinical or administrative staff receives such a request, the staff member forwards the call to the manager or director of the department who will speak directly to you. The manager or director will instruct you to complete the Availability of UM Criteria to Practitioner/Request for On-site Visit Form. Once we receive the written request, the manager or director will schedule an appointment with you to come on site to review the criteria we utilized to make the UM decision. During the scheduled visit, we will review with you the criteria online via our CCMS system. You also have the right to request a physician-to-physician meeting at this time to discuss the criteria further.

We document all requests and visits within our CCMS system.

 


 
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