The Plan requires notification for all inpatient admissions and certain inpatient and intermediate behavioral health services. In addition, facilities may be required to provide updated clinical information for authorization of continued stays. This document applies to notification and the authorization of continued stays via medical necessity review.

Admitting providers and facilities are responsible for notifying The Plan and/or obtaining continued stay authorization as appropriate. Please see additional documentation including Provider Manuals and payment policies are available in the Provider Resource Center on the Tufts Health Plan web site:

• Harvard Pilgrim Health Care Commercial Products – Harvard Pilgrim Health Care Provider Manual
• Tufts Health Commercial Products-Tufts Health Plan Commercial Provider Manual
• Tufts Health Plan Direct, Tufts Health Together and Tufts Heal Unify-Tufts Health Public Plans Provider Manual
• Tufts Health RITogether-Tufts Health Public Plans Provider Manual

Clinical Guideline Coverage Criteria

Behavioral Health Intermediate (inclusive of Non-24-Hour and Diversionary Services) Level of Care:

The Plan uses InterQual^® criteria for determining medical necessity for behavioral health levels of care post notification. Please see below for specific details:

1. The Plan uses InterQual criteria for the following services:
1. Partial Hospitalization Services (PHP) * Applies to Harvard Pilgrim Health Care Commercial, Tufts HealthPlan Commercial, Tufts Health Plan Direct, Tufts Health Plan Together, and Tufts Health Plan Unify.
2. The Plan uses ASAM (American Society of Addiction Medicine) criteria for determining medical necessity for the following services for RITogether:
1. Partial Hospitalization Services (PHP) for substance use disorders-(ASAM Level 2.5)

InterQual Criteria are nationally recognized medical necessity behavioral health criteria developed by a clinical research staff, which includes physicians, registered nurses, and other health care professionals. The clinical content of the criteria is annually reviewed, updated, and validated by a national panel of clinicians and medical experts, including those in community and academic practice settings, as well as within the managed care industry throughout the United States.

ASAM Criteria are nationally recognized treatment criteria for addictive, substance-related and dual diagnosis conditions that support decisions regarding available treatment or service options. Refer to An Introduction to the ASAM Criteria for Patients and Families for additional description.