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Commercial Plans Behavioral Health

Benefits

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:

  • Logging in to the secure provider website
  • Using the Interactive Voice Response (IVR) system by calling 800-208-9565
  • Speaking to a Mental Health Coordinator at 800-208-9565. The mental health department is open Monday, Tuesday, Wednesday and Friday from 8:30 a.m. – 5 p.m. and Thursday from 9 a.m. – 5 p.m.

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.

plans card