Tufts Health Plan Outpatient Physical Therapy prior authorization requirements (2026)
What Tufts Health Plan generally requires to approve Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035), for Commercial (1 eval + 8 visits default); Public Plans differ plans. Yes. Tufts Health Plan generally requires prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035).
Medical-necessity criteria Tufts Health Plan generally applies
Outpatient PT/OT/ST is reviewed against Change Healthcare InterQual criteria. The Tufts Commercial referral default covers 1 evaluation plus 8 treatment visits; prior authorization is required beyond the initial allowance. (Tufts Health Public Plans Together/RITogether: initial evaluation plus 11 PT visits per benefit year without PA.) Submitted via the MHK Portal; precertification fax 617-972-9409.
Commonly required documentation
- Evaluation, functional deficits, and plan of care
- clinical information supporting InterQual medical necessity for visits beyond the allowance.
How to submit
- Method: MHK Portal (precert fax 617-972-9409)
- Portal: MHK Portal
Source
Source: Tufts Commercial Provider Manual + Outpatient PT/OT/ST Medical Necessity Guidelines (Point32Health). Public-plan thresholds differ. Last verified 2026-06-17.
Frequently asked questions
Does Tufts Health Plan require prior authorization for Outpatient Physical Therapy?
Yes. Tufts Health Plan generally requires prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035).
What does Tufts Health Plan require to approve Outpatient Physical Therapy?
Outpatient PT/OT/ST is reviewed against Change Healthcare InterQual criteria. The Tufts Commercial referral default covers 1 evaluation plus 8 treatment visits; prior authorization is required beyond the initial allowance. (Tufts Health Public Plans Together/RITogether: initial evaluation plus 11 PT visits per benefit year without PA.) Submitted via the MHK Portal; precertification fax 617-972-940… Always confirm against the current Tufts Health Plan policy.
How long does a Tufts Health Plan prior authorization take?
Turnaround varies by plan and submission method. Check the Tufts Health Plan portal for current timeframes.
Submitting Outpatient Physical Therapy to Tufts Health Plan?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.