Introduction to Tufts Health Plan Purpose of This Manual

Introduction to Tufts Health PlanDepartment Contact ResponsibilityClinical ServicesCase ManagementCare Manager1-888-766-9818 • Concurrently reviews Tufts Health Planmembers hospitalized at Tufts Health Planfacilities• Coordinates and authorizes discharge plans,including rehabilitation, Skilled NursingFacility (SNF) or chronic hospitalplacement, home health care, hometherapies, and Durable Medical Equipment(DME)Specialty Care Manager 1-888-766-9818 • Facilitates discharge planningMental Health Department• Provides ongoing coordination of servicesthrough the continuum of illness ofmedically complex cases• Acts as plan liaison for members, families,providers and vendors of ancillary services• Manages medically complex cases• Performs out-of-network hospital reviewsand discharge planning• Manages high-risk obstetrics, pediatrics,neonatology, transplants, HIV/AIDS,disabilities, rehabilitation nursing, andoncology casesMental Health Outpatient ClinicalCoordinator and ServiceRepresentative1-800-208-9565 • Manages requests for outpatient mentalhealth and substance abuse (MH/SA)services• Coordinates members’ access to inpatientMH/SA servicesMental Health Care Manager 1-800-208-9565 • Facilitates discharge planning for membershospitalized at Designated Facilities (DFs)Precertification Department• Monitors quality of care at mental healthDFsPrecertification Clinical Staff 617-972-9409 (fax) • Coordinates any federal mandates• Authorizes utilization management ofcertain outpatient procedures including, butnot limited to, elective surgeries, selectedmedication, and experimental procedures2 Tufts Health Plantuftshealthplan.com/providers