Medical Necessity Guidelines

The Medical Necessity Guidelines below detail coverage criteria for Harvard Pilgrim Health Care and Tufts Health Plan lines of business. We encourage you to use the drop-down menu to filter by product. We note line of business under the guideline name; the policy may not apply to every product in that line of business. For product applicability, refer to the policy. We encourage electronic submission of prior authorization requests via our secure portals (Harvard Pilgrim Health Care; Tufts Health Plan).

Tufts Health Together utilizes MassHealth’s Unified Formulary for select medical benefit drugs (see the MassHealth Drug List).

Additional resources: In addition to these policies, please refer our to our Prior Authorization page and our handy Prior Authorization grids and tools, as well as our Provider Manuals for our notification, administrative authorization, and referral policies.

About Our Medical Criteria & Provider Feedback

The Plan develops clinical policies based on sound evidence to evaluate the medical apprioriateness of health care services. Learn more about this process and on providing clinical feedback.

Accessing InterQual criteria: Some of our Medical Necessity Guidelines utilize InterQual® criteria, as detailed in applicable policies. You may view this criteria on the Optum One Health website (for Harvard Pilgrim; for Tufts Health Plan). For more information, please refer to these instructions on creating a One Healthcare ID and setting up an authenticator for use with the One Healthcare ID.