Out-of-Network Coverage at the In-Network Level of Benefits

Tufts Health Plan requires prior authorization for members to be covered for services from out-of-network providers at the in-network level of benefits. Without prior authorization, members of Commercial plans, including limited network plans, will not be covered for out-of-network services (since those products have no out-of-network benefits), and PPO/POS members will only be covered for such services at their plan’s out-of-network/unauthorized level of benefits. In limited special circumstances, when it is medically necessary to do so and such services are not sufficiently available in network, Tufts Health Plan may authorize members to obtain services from out-of-network providers at the in-network level of benefits. These guidelines provide the prior authorization criteria Tufts Health Plan will use to determine whether it is medically necessary for a member to receive services from an out-of-network provider. The new criteria to be used to review requests for prior authorization are documented in the Medical Necessity Guidelines for Out-of-Network Coverage at the In-Network Level of Benefits (All Plans).

Source: https://tuftshealthplan.com/documents/providers/guidelines/medical-necessity-guidelines/oon-coverage