Medical necessity guidelines

The Medical Necessity Guidelines below detail coverage criteria for Harvard Pilgrim Health Care and Tufts Health Plan. 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). Or if you prefer, via fax.

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

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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 appropriateness 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.

Rhode Island PCPs and prior authorization

In accordance with the Rhode Island Prior Authorization Reform Act of 2025, effective Oct. 1, 2025, prior authorization requests may not be needed for certain services for Rhode Island members enrolled in our Tufts Health RITogether and Harvard Pilgrim Health Care fully insured Commercial plans — when the requesting physician is a contracted primary care physician and the services are being provided in the normal course of primary care treatment. For details, please refer to this FAQ.