Behavioral Health Inpatient Level of Care Determinations Form

Harvard Pilgrim Tufts Health Plan Medical Necessity Guidelines: Behavioral Health Inpatient Level of Care Determinations

Effective: November 1, 2023

REQUIRED, submit supporting clinical documentation pertinent to service request to the FAX numbers below.

• Notification Required Yes ☐ No
• F REQUIRED, concurrent review may apply

Applies to:

• Commercial Products
• Harvard Pilgrim Health Care Commercial products; 800-232-0816
• Tufts Health Plan Commercial products; 617-972-9409
• CareLinkSM – Refer to CareLink Procedures, Services and Items Requiring Prior Authorization

Public Plans Products

• Tufts Health Direct – A Massachusetts Qualified Health Plan (QHP) (a commercial product); 888-415-9055
• Tufts Health Together – MassHealth MCO Plan and Accountable Care Partnership Plans; 888-415-9055
• Tufts Health RITogether – A Rhode Island Medicaid Plan; 857-304-6404
• Tufts Health Unify* – OneCare Plan (a dual-eligible product); 857-304-6304

*The MNG applies to Tufts Health Unify members unless a less restrictive LCD or NCD exists.

Senior Products

• Harvard Pilgrim Health Care Stride Medicare Advantage; 866-874-0857
• Tufts Health Plan Senior Care Options (SCO), (a dual-eligible product); 617-673-0965
• Tufts Medicare Preferred HMO, (a Medicare Advantage product); 617-673-0965
• Tufts Medicare Preferred PPO, (a Medicare Advantage product); 617-673-0965

Note: While you may not be the provider responsible for obtaining prior authorization or notifying Point32Health, as a condition of payment you will need to ensure that any necessary prior authorization has been obtained and/or Point32Health has received proper notification. If notification is required, providers may additionally be required to provide updated clinical information to qualify for continued service. The Plan requires notification for all inpatient admissions including behavioral health inpatient services. In addition, facilities may be required to provide updated clinical information for authorization of continued stays (\

Members may access materials by logging into their online account (visit www.harvardpilgrim.org, click on Member Login, then Plan Details, Prior Authorization for Care, and the link to clinical criteria) or by calling Member Services at 888-333-4742

For Tufts Health Plan Members: To obtain InterQual® SmartSheets™

• Tufts Health Plan Commercial Plan products: If you are a registered Tufts Health Plan provider click here to access the Provider Website. If you are not a Tufts Health Plan provider, please click on the Provider Log-in and follow instructions to register on the Provider website or call Provider Services at 888.884.2404
• Tufts Health Public Plans products: InterQual® SmartSheet(s) available as part of the prior authorization process

Tufts Health Plan requires the use of current InterQual® Smartsheet(s) to obtain prior authorization. In order to obtain prior authorization for procedure(s), choose the appropriate InterQual® SmartSheet(s) listed below. The completed SmartSheet(s) must be sent to the applicable fax number indicated above, according to Plan

Clinical Guideline Coverage Criteria

Behavioral Health Inpatient (inclusive of Mental Health and Substance Use Disorder) Levels of Care

The Plan uses InterQual®* and American Society of Addictive Medicine (ASAM)^ criteria for determining medical necessity for behavioral health levels of care. Please see below for specific details:

1. The Plan uses InterQual criteria for determining continued stay post notification for:
   • Acute inpatient services
     • The Plan provides coverage for special resources or accommodations if Member's immediate care requires adjustments to a facility's usual staffing needs. For Massachusetts plans, The Plan will approve coverage in accordance with accepted practice and/or federal and state standards.
   • Acute residential services/24-hour diversionary services
   • All Substance Use Disorder (SUD)-specific inpatient levels of care unless otherwise specified
2. The Plan uses ASAM (American Society of Addiction Medicine) criteria for determining medical necessity for the following services:
   • Tufts Health RITogether: All SUD-specific levels of care (ASAM Level 4 and Levels 3.1-3.7)
   • Tufts Health Together/Tufts Health Unify/Tufts Health Plan SCO: Residential Rehabilitation Services(ASAM level 3.1)

^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.

*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.