We’re offering some guidance around best practices and tips for utilization management (UM) requests and transactions so that Point32Health and our provider partners can work together as efficiently as possible for a positive shared experience.
These tips highlight just a few common issues and opportunities for improved collaboration, based on feedback from our provider community and our UM staff who work to help facilitate essential functions so that our providers can continue to deliver best-in-class care to our member population.
Benefits and eligibility and new MHK access for 1/1
When looking to confirm a member’s benefits and eligibility prior to initiating care or referring them for a service, the best place to start is our secure provider portals. The following reference guides offer more guidance on how to use the portals to verify benefits and eligibility:
As a reminder, we encourage you to use the electronic self-service capabilities offered via the provider portals whenever possible for their ease of use and quick turnaround times. HPHConnect and MHK — which is the medical management tool accessed from within the Tufts Health Plan secure portal — allow you to perform a number of transactions efficiently in one place, such as submitting referrals and authorizations, finding the status of a claim, providing inpatient notification, and more.
And we’re delighted to share that beginning Jan. 1, 2026, providers will be able to use MHK to perform all their essential transactions for our Tufts Health One Care members! This access is new for Tufts Health One Care, and represents the most direct way to submit requests, providing real-time determinations and allowing you to attach clinical documentation and notes. (Please note that MHK is not currently available for Tufts Health Plan Senior Care Options, but it is available for Tufts Health Plan Commercial, Tufts Health Public Plans, and Tufts Medicare Preferred.)
Updating an authorization
If you initiated a request for prior authorization but need to make any changes to the information (e.g., the number of visits listed, diagnosis or procedure codes, the date range), the authorization should be submitted again as a new request. While we encourage you to use the applicable provider portal to do this, you may also choose to submit the request via fax.
After submitting a request either via the portals or by fax, please allow Point32Health a reasonable amount of time to review the request and respond. Submitting multiple requests unnecessarily may delay processing, as our UM team will need to review each request separately.
Include all necessary information
Please remember to include all pertinent information when submitting an authorization or other UM request. This includes any appropriate clinical documentation, the provider’s NPI or TIN, or any other identifying information necessary to convey a complete picture of the request or encounter so that we can process it without the need for provider resubmission.
Provider Service Center
For assistance with any functions you’re unable to perform using our electronic self-service tools, we encourage you to contact the Provider Service Center at the applicable phone number as outlined by line of business here. We do not recommend calling other Point32Health departments such as UM directly for support, as the Provider Service Center is staffed and trained more appropriately to handle such inquiries.