We’re sharing some important reminders regarding new prior authorization requirements for Tufts Medicare Preferred and Tufts Health Plan Senior Care Options (SCO) members — some of which took effect on Jan. 1, 2025, and some of which will be effective for dates of service beginning March 1, 2025.
Jan. 1, 2025: acute inpatient rehabilitation and non-emergent medical transportation
In the November 2024 issue of Insights and Updates for Providers, Point32Health announced a number of new prior authorization requirements for Senior Products, which took effect on Jan. 1, 2025. Among those prior authorization updates, we want to call particular attention to the following new requirements:
- Prior authorization is now required for the acute inpatient rehabilitation level of care for members of our Tufts Medicare Preferred and Tufts Health Plan SCO products. Medicare Benefit Policy Manual Chapter 1 is utilized for prior authorization coverage criteria.
- For Tufts Medicare Preferred only, prior authorization is required for non-emergent medical transportation (ambulance) codes A0426, A0428, A0430, and A0435, and we follow Medicare Benefit Policy Manual Chapter 10 for criteria. In addition to the broader communication about new prior authorization requirements for Senior Products for Jan. 1, you can find further information about this change in this supplementary article specific to non-emergent medical transportation.
March 1, 2025: skilled nursing facility care and long-term acute care
As we announced in the January issue of Insights and Updates for Providers, updates to our Tufts Medicare Preferred (HMO and PPO) Prior Authorization, Notification, and No Prior Authorization Medical Necessity Guidelines take effect on March 1, 2025 for Tufts Medicare Preferred members only. Point32Health would like to reminder our provider network of these particularly notable authorization updates included in that work:
- Prior authorization will be required for skilled nursing facility care, and we will follow Medicare Benefit Policy Manual Chapter 8 for prior authorization coverage criteria.
- We will also require prior authorization for long-term acute care, using Medicare Benefit Policy Manual Chapter 1 for coverage criteria.
- Submitting prior authorization requests is more efficient using Tufts Health Plan’s secure online provider portal. If your facility is not yet registered for the provider portal, we encourage you to do so now.
Refer to the Medicare Benefit Policy Manual and Point32Health’s prior authorization resources page for complete information.