How to Fill Out and Submit the Tufts Health Plan Referral Form

The Tufts Health Plan referral form is the document your primary care provider (PCP) sends to the plan before you see a specialist, so the visit processes as a covered, in-network claim. You don’t fill it out yourself. Your PCP’s office does, and getting it submitted and approved before the appointment is what keeps the claim from being denied (HMO) or paid at the costlier out-of-network rate (POS). Tufts Health Plan is now administered under the Point32Health brand, but the referral process works the same way.

Who Actually Needs a Referral

It depends on your product. HMO members must have a PCP referral for specialist visits as a condition of coverage. POS members can see a specialist without one, but the visit then processes at the out-of-network benefit level, which usually means a much higher cost share.¹

A number of services never require a referral:¹

OB/GYN care, including annual preventive exams, maternity care, and emergency gynecologic conditions, when provided by a contracting OB/GYN, certified nurse midwife, or family practitioner.
Outpatient behavioral health from licensed, in-network providers.
Emergency department visits, qualified urgent care centers, and limited-service clinics like MinuteClinics, including lab work ordered at those facilities.
Lab work, radiology, and anesthesia (though some radiology and anesthesia services still require a separate prior authorization).
Chiropractic, oral surgery, and dialysis.
Covered practitioner services provided during an inpatient hospital stay.

Federal law reinforces the emergency piece. Under the No Surprises Act, your plan cannot deny coverage because you went to an emergency room without approval first, even if the facility is out of network.²

What Goes on the Form

You don’t complete the form, but knowing what it asks for lets you spot errors before they turn into a billing dispute. The paper form has four sections.¹

Member Information

Your full name, date of birth, and Tufts Health Plan member ID from the front of your insurance card. The referral date goes here too, and it must come before the specialist’s date of service. Backdating after the visit won’t work. If you’re on a limited-network plan, the form flags it so the office can confirm the specialist is in your specific network.

Provider Information

Two blocks: one for the PCP, one for the specialist. Each needs the provider’s full name, National Provider Identifier (NPI), address, and phone number. Both NPIs are mandatory. The specialist’s block also asks for the specialty and whether the specialist is in your network.

Type of Referral

Three categories:

In-plan, meaning a referral to a specialist inside the Tufts network. The PCP’s signature is the only approval needed.
Out-of-plan, meaning a specialist outside the network. These require both the PCP’s signature and a physician reviewer’s approval, plus the diagnosis, any diagnostics already done, and the reason an in-network provider cannot handle the care.
Out-of-network for limited-network members, which also requires Tufts Health Plan review.

Services Requested

The PCP picks one service category and the number of authorized visits:

Consultation: one visit.
Consultation / second opinion: one visit.
Consultation with diagnostic studies: up to three visits.
Consultation, diagnostics, and treatment: PCP enters the visit count; blank defaults to one.
Physical or occupational therapy: defaults to one evaluation plus eight treatment visits.
Speech therapy: PCP writes in the number of visits.

The PCP signs and dates the form. Out-of-plan referrals also need a physician reviewer’s signature.

How the Referral Gets Submitted

Tufts Health Plan prefers electronic submission through its secure Provider portal, which generates a referral number right away.¹ Paper forms can also be faxed to a product-specific number.³

Standard referral decisions typically come within two business days of the plan receiving everything it needs.¹ Once approved, the referral generates an authorization number that must be attached to every claim the specialist files for that course of care.

How Long the Referral Lasts

A Tufts Health Plan referral is good for up to one year from the referral date, unless something ends it sooner:¹

You use up the approved number of visits.
You hit your plan’s benefit limit for that service.
You lose eligibility, such as by switching plans or leaving your employer.
Your PCP put a shorter date range on the form.

PCPs can set a shorter window but cannot go beyond one year. If you run out of visits before the referral expires, your PCP’s office has to file a new one. Keep your own count. The specialist’s office doesn’t always warn you when you’re close to the limit.

A Referral Is Not a Prior Authorization

These two get confused constantly, and the difference costs people money. A referral is your PCP sending you to a specialist and telling the plan to pay for the visits. A prior authorization is Tufts Health Plan separately reviewing whether a specific service, drug, device, or piece of equipment is medically necessary.¹

So a referral to an orthopedic surgeon does not automatically cover an MRI. High-tech imaging such as MRIs, CT scans, and PET scans goes through a separate prior authorization program managed by Evolent. The ordering provider handles the authorization, but the imaging facility has to confirm an authorization number exists before the scan.⁴ If your specialist orders imaging, ask the office to confirm the prior authorization is in place before you show up.

If the Referral Is Denied

Start with an internal appeal through Point32Health. The denial notice will state the reason and the deadline. If the internal appeal upholds the denial, you can ask for an external review by an independent third party. You have four months from the final internal denial to file the external review request. The reviewer must decide within 45 days for standard cases, or within 72 hours for medically urgent situations.⁵ External review costs either nothing or no more than $25, depending on whether your state’s process or the federal process applies.

Federal rules give you the right to appeal denials that turn on medical judgment, including a plan’s finding that a visit isn’t medically necessary or that a treatment is experimental.⁵

Checks to Run Before Your Appointment

Call your PCP’s office a few days before the visit and confirm the referral has been submitted and approved. An approved referral number is your proof that the visit will be covered.⁶
Check your member ID on the referral. A single transposed digit stalls everything.
If you’re on a limited-network plan, verify the specialist is in your specific network, not just contracted with Tufts generally.
If the specialist is likely to order imaging, surgery, or specialized equipment, ask at the first visit whether anything will need its own prior authorization. Finding out early is cheaper than finding out from a denied claim.

1
Point32Health. Commercial Provider Manual Referrals, Prior Authorizations and Notifications
2
U.S. Department of Labor. Avoid Surprise Healthcare Expenses: How the No Surprises Act Can Protect You
3
Point32Health. Reminder on Referrals
4
Point32Health. Evolent (formerly National Imaging Associates)
5
HealthCare.gov. External Review
6
Tufts Health Plan. Frequently Asked Questions