Effective January 1, 2026, MassHealth discontinued the Tufts Health Together Managed Care Organization (MCO) product (All Provider Bulletin 410); members previously enrolled in the MCO were reassigned, where possible, to the health plan participating with their existing PCP. Tufts Health Together now exists only as two Accountable Care Partnership Plans — with Cambridge Health Alliance and with UMass Memorial Health — which remain active and are the only Tufts Health Together products for intake to route to. Tufts Health Together is (and remains) the only MassHealth plan family that self-manages behavioral health: no Carelon, no Optum — Point32Health's internal UM reviews ABA against its own medical-necessity guideline using InterQual criteria and SmartSheets, on Point32Health's own ABA PA form rather than the Massachusetts standard form every other administrator takes.
Per the October 2025 provider update, Tufts Health Together adopted InterQual criteria with InterQual SmartSheets for ABA prior-authorization review, with a new ABA medical-necessity guideline effective January 1, 2026 — and moved members onto Point32Health's own updated ABA PA form. Requests submit electronically through the MHK portal on the secure Provider portal with the form uploaded, or by fax to 888-977-0776 — the fax the form itself names for Tufts Health Together ("For Tufts Health Together, fax this form to 888-977-0776"). The October 2025 notice lists that number only under Tufts Health Direct because it is the Tufts Health Public Plans behavioral-health fax both products share. Even the initial evaluation needs approval: the form's "Request for Initial Evaluation" (pages 1-3) goes in with copies of the child's IEP and the comprehensive diagnostic evaluation, and continued services use pages 1-6, with units requested per 6-month period and modifier U2 on Together codes. For a practice running one MA workflow, this is the exception to build: a Tufts Together family means the Point32 form and the Point32 portal, and a standard-form packet sent here is a bounce. The benefit itself matches the state baseline — no published hour caps, and sole-diagnosis Down syndrome coverage effective January 1, 2026 explicitly includes Tufts Health Together.[4][2][3][18][19]
Point32Health's February 2026 provider update states that "all contracted ABA providers must obtain accreditation from a nationally recognized accrediting body specializing in ABA" — a requirement that "supports a MassHealth initiative" and that Point32 extended to all Harvard Pilgrim and Tufts Health Plan products, Tufts Health Together included. The deadlines: center-based ABA providers in Massachusetts and Rhode Island must be accredited by January 1, 2027; all other providers by January 1, 2028, after which every ABA provider, new ones included, must be accredited. That makes accreditation a network-participation gate, not a quality nicety — budget the timeline into any Tufts network strategy. The same update changed how to request authorization: submit ABA PA requests for any Point32Health member under the practice's billing (type 2) NPI, not the individual therapist's. Worth knowing on the enforcement front: Point32Health formally disputed MassHealth's 2026 ABA supervision-audit methodology (February 9, 2026) — but the statewide 1:10 expectation still makes supervision staffing the safe operating assumption.[1][9]
Point32Health’s 2026 Public Plans claims chapter sets the clock for Tufts Health Together: “For first time claims submissions, the filing deadline is 90 calendar days from the date of service (for professional or outpatient claims),” and claims received after that window “will be denied for failure to meet timely filing requirements.” When Tufts is secondary, the claim is due within 60 calendar days of the date on the primary carrier’s EOP or third-party determination letter (60 days from a retraction statement). Late charges follow the same 90-day rule, and corrected claims (frequency code 7, or “Corrected Claim” and the original claim number on paper with a Request for Claim Review Form) go in on the timeframe in your provider contract. Payment disputes must be filed within 60 calendar days of the EOP on which the claim first denied, with a maximum of two appeal levels. Appeals of timely-filing denials are reviewed only for the MassHealth exceptions in G.L. c. 118E, § 38: the member was enrolled retroactively, the member did not tell you about MassHealth eligibility in time, or MassHealth expressly authorized the exception.[14]
Payment: the chapter publishes no clean-claim day count. It uses MassHealth’s definition of a clean claim (one that “can be processed without obtaining additional information from the provider of the service or from a third party”) and says the explanation of payment “is a weekly report of all claims that have been paid or denied,” viewable with 835 remittances through Payspan Health. No submission cutoff day or time is published.[14]
Point32Health’s Tufts Health Together ABA guideline (effective January 1, 2026, revised February 18, 2026) lists the codes that require prior authorization: 97151, 97153, 97154, 97155, 97156, 97157 and H0031, described as “Mental health assessment, by non-physician - Assessment and treatment planning by a BCBA.” The guideline’s history records that H0032, H2012 and H2019 were removed in April 2023 when the CPT codes were added. 97152, 97158, 0362T and 0373T are not on the list. The eligible diagnoses are F84.0, F84.3, F84.5, F84.8 and F84.9, plus Q90.0–Q90.9 (Down syndrome) from January 1, 2026.[5]
Point32Health’s Together guideline lists the continuing-stay criteria. The treatment plan “is updated no less than every six months” and includes “Data demonstrating change from baseline across treatment goals,” data from updated assessment tools as applicable, and updated or added goals. Progress must be “monitored regularly and appropriately documented by: a. Behavioral graphs that visually demonstrate changes from baseline; and b. Daily session notes” covering the treatment provided, how treatment time was used and the member’s response. Where progress stalls, the request must show the barriers found and what was done about them (protocol changes, other services, reassessment); lack of progress “does not inherently warrant an increase in service hours.” Utilization below 75% of approved direct hours over a review cycle may trigger extra review, and a continued request must show the steps taken to address adherence barriers.[5]
The questions that decide whether a family can start with Tufts Health Together (Point32Health), and what they have to bring. Each maps onto something intake should ask on the first call.
EPSDT sets the bound, and nothing else does. ABA is covered for MassHealth Standard and CommonHealth members under 21, and for Family Assistance members under 19 — with no lower age bound and no dollar, visit or unit-of-service cap underneath it. For the youngest referrals the binding rule is non-duplication rather than age: ABA cannot duplicate services the child already receives through Early Intervention. From 1/1/2026 the second diagnostic pathway (sole-diagnosis Down syndrome) rides the same age structure. Confirm the member is on one of the two surviving ACPPs — the Together MCO product was discontinued 1/1/2026.[10]
Point32Health's own ABA PA form names them, and its list is narrower than the Massachusetts standard form's. The initial-evaluation request must carry a "Comprehensive diagnostic evaluation completed by a neurologist, pediatrician, psychiatrist, psychologist, or other licensed physician experienced in autism or Down syndrome treatment," and the form asks the diagnostician's licensure from a fixed list: neurologist/pediatric neurologist, developmental pediatrician, psychiatrist, psychologist, or "other licensed physician experienced in the diagnosis and treatment of autism or Down syndrome." Nurse practitioners and physician assistants, which the MassHealth standard form accepts, are not on it — so an APRN- or PA-made diagnosis is a question to raise with Point32 before submitting. The form itself is the BCBA's: "The Board-Certified Behavioral Analyst (BCBA) rendering and/or supervising the autism services should complete this form. Point32Health Plans will not approve the request if completed by a non-BCBA provider."[18]
Permitted at the family's request, with no ABA-specific code list. The ABA provider "may deliver services and consultation via a Health Insurance Portability and Accessibility Act (HIPAA)-compliant telehealth platform at the parent/caregiver's request and if the service can be effectively delivered via telehealth as part of the intervention when appropriate," with the rationale documented and the documentation reflecting "clinical considerations for appropriateness across any service components being delivered via telehealth." Two guardrails ride along: telehealth "must not replace in-person availability," and the member or family "may rescind consent for telehealth at any time without risk of interruption of services." The specification itself publishes no per-code restriction, modifier or place-of-service code. Point32Health publishes no telehealth position for Together ABA, and the performance specification is MBHP's, not Point32's. State floor, which binds this plan: Managed Care Entity Bulletin 115 (April 2024) requires every MassHealth ACPP, MCO and the behavioral-health vendor to keep a telehealth policy "no more restrictive than" All Provider Bulletin 379. That bulletin allows any covered service outside a short excluded list (ABA is not on it), so the 97151 assessment and 97155 supervision included, by live video or audio-only when clinically appropriate and with member consent, paid at parity with in-person and billed with POS 02 (not in the home) or POS 10 (in the home) and modifier 95 (audio-video) or 93 (audio-only). No minimum share of in-person supervision is published.[7][12][13]
Ask the plan: Point32Health provider services / the Tufts Health Public Plans provider manual — Together members use Point32Health's own ABA PA form and, from 1/1/2026, InterQual criteria, so the Massachusetts standard-form answers are the floor rather than the rule here.
The legal maximum is 7 calendar days, but Point32Health's manual still prints 14. Its 2026 Utilization Management chapter (last revised 4/7/2026) says "Prospective non-urgent requests will be completed within 14 calendar days" for Tufts Health Together. Urgent requests are decided "not later than 72 hours of receipt of the request," with a possible 14-calendar-day extension. The federal managed-care rule, for rating periods that start on or after 1/1/2026, caps standard decisions at "7 calendar days after receiving the request for service," plus up to 14 more calendar days on request or with justification. WellSense and Carelon moved their MassHealth decisions to 7 days on January 1, 2026, and the federal limit is the one that binds. Point32Health asks providers to "Submit a prior authorization request at least five business days in advance of the scheduled procedure, service, or planned admission." For reauthorization, file at least that far before the current authorization ends. The provider "must have this authorization letter before providing any service(s) requiring an authorization."[23][19][24][25][26]
Ask the plan: Point32Health utilization management: confirm it applies the 7-calendar-day standard for Tufts Health Together requests received from 1/1/2026 (the 2026 manual still says 14).
Tufts Health Together pays last. "Federal and state regulations mandate that as a Medicaid managed care organization, Tufts Health Public Plans is payer of last resort for Tufts Health Together." Providers "must submit the claim(s) to all known available carriers as the primary insurer and receive an explanation of payment or equivalent." They then submit to Tufts with that EOP. The EOP must show the processed or check date and explain any remark codes. "Do not take a cost-sharing amount up front." An administrative denial from the primary carrier (a claim-preparation error, or missing information) "is not accepted as a reason for Tufts Health Public Plans to pay as a primary carrier." A COB claim is due "60 calendar days from the date on the original primary carrier's EOP." MassHealth's own rule adds that a primary denial for missing PA or for being out of network forfeits the secondary payment (130 CMR 450.316(B)). TRICARE pays before MassHealth: "By law, TRICARE pays after all other health insurance, except for: Medicaid."[14][27][28]
Ask the plan: Point32Health: whether Tufts Health Together also requires its own ABA PA when it is secondary. The claims chapter does not say.
Not published. Point32Health's October 2025 ABA update moved review onto InterQual criteria with SmartSheets from 1/1/2026 and moved Together members onto Point32Health's own ABA PA form, and neither document states how recent the diagnostic evaluation must be. The MassHealth-wide position is the same — no recency window is published on the state standard form either.[4][11]
Blocked on: Point32Health provider services / the Tufts Health Public Plans provider manual — Together members use Point32Health's own ABA PA form and, from 1/1/2026, InterQual criteria, so the Massachusetts standard-form answers are the floor rather than the rule here.
No instrument is mandated. The standard form requires a comprehensive assessment "which aligns with DSM criteria across ASD core deficits" without naming ADOS-2, ADI-R, CARS-2 or any other tool, and the performance specification names no diagnostic battery either; the Down syndrome pathway replaces the instrument question entirely with genetic testing. Massachusetts puts its measurement requirement downstream of intake instead — in progress documentation and medical-necessity review, not in the diagnostic gate. Point32Health publishes no ABA diagnostic-instrument requirement of its own; from 1/1/2026 its ABA reviews run on InterQual criteria and SmartSheets.[11][4]
Blocked on: Point32Health provider services / the Tufts Health Public Plans provider manual — Together members use Point32Health's own ABA PA form and, from 1/1/2026, InterQual criteria, so the Massachusetts standard-form answers are the floor rather than the rule here.
Mostly no. Point32Health's 2026 Public Plans Provider Manual applies its PCP-referral rule only to "Tufts Health Together with Cambridge Health Alliance (CHA)": specialty services outside the CHA ACO network need a valid referral on file, normally valid for one year or the approved number of visits, and "Tufts Health Together members do not require a PCP referral for services designated by MassHealth as exceptions to referral requirements as communicated and/or referenced in All Provider Bulletin 409." For other Together members no referral applies. No physician order is a condition of ABA authorization: the Massachusetts standard ABA request has no referral field and is completed by the BCBA/LABA, and the MBHP performance specification's referral language is about the 14-day timeliness standard. APB 409 (October 2025), read in full, does not name ABA among its added exceptions, but it builds on the base list in 130 CMR 450.118(J)(5), which exempts “services delivered by a behavioral health provider (including inpatient and outpatient psychiatric services)” from the PCC referral requirement. Point32 has not said in writing whether it treats an ABA agency as a behavioral health provider for that exception.[15][16][19][7]
Ask the plan: Tufts Health Public Plans Provider Services, 888-257-1985 — for a CHA-attributed member, ask whether ABA from a non-CHA provider needs a PCP referral on file, or whether Point32 applies the 130 CMR 450.118(J)(5)(p) behavioral-health-provider exception.
Coverage decides whether Tufts Health Together (Point32Health) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Point32Health runs Tufts Health Public Plans behavioral-health review in-house and has not published an ABA supervision ratio for the Together product. Point32Health’s October 2025 update moved commercial and Tufts Health Direct ABA review onto InterQual criteria from January 1, 2026, and Together members use Point32Health’s own ABA prior-authorization form rather than the Massachusetts standard form — but neither document states a supervision percentage. The MassHealth-wide 10–25% band remains the state-level floor the CY2024 audit was run against.[7]
Blocked on: Point32Health provider services / the Tufts Health Public Plans provider manual; note the Together MCO was slated for discontinuation effective January 1, 2026, so confirm the member’s current product first.
Not published for 97153 with 97155. Point32Health’s ABA payment policy (rev. 05/2026), which applies to Tufts Health Together, does not reimburse “Services provided concurrent with another treatment modality, such as occupational or speech therapy, where the ABA provider’s role is to escort/accompany the member to the appointment.” Its General Coding and Claims Editing policy applies generic incidental and mutually-exclusive edits but no ABA rule.[20][21]
Ask the plan: Tufts Health Public Plans Provider Services, 888-257-1985 — ask whether a BCBA’s 97155 pays for the same minutes as the technician’s 97153 on a Together claim.
Massachusetts is a no-cap state that nonetheless has one published per-day number. There are no annual, lifetime or unit-of-service ceilings on the EPSDT benefit, and 101 CMR 358.03 is a rate regulation, not a limit regulation — it fixes per-15-minute rates and states they are “full compensation” including “necessary administration and professional supervision associated with patient care.” The only per-day cap in the performance specification is for group instruction, which “may occur up to 4.5 hours a day as clinically indicated, in groups of 2-8 Members.” No per-code MUE regime is published, so what bites in practice is medical-necessity review and the supervision-ratio audit, not a unit edit. Point32Health’s Maximum Units payment policy (rev. 09/2026) does apply to Tufts Health Together: “Effective for DOS beginning May 1, 2026, Tufts Health Plan products will apply and adhere to CMS and/or Medicaid MUE unit limitations where applicable,” units billed beyond the maximum are not paid, and a medically necessary excess can be appealed with supporting records. The policy does not say which table (CMS practitioner or Medicaid) sets the ABA numbers for this MassHealth plan.[8][22]
Ask the plan: Point32Health provider services (Tufts Health Public Plans, 888-257-1985): ask whether the CMS practitioner MUE (97153 = 32 units/day) or a Medicaid MUE applies to Together ABA claims.
Home and community, with school carved out. ABA “is delivered by a contracted and credentialed provider in a variety of settings within a Member’s home and community,” and “services provided in a school setting are distinct and separate from those covered by the health plan and are typically covered by the educational system’s special education resources as part of the Individualized Education Program (IEP) pursuant to Public Law 94-142.” Providers “must not direct, limit, or discourage access to other medically necessary or school-based services.” Transition planning contemplates moving a member “from a center based setting to home/community settings,” so centers are in scope. Group homes are not addressed. No Together-specific deviation is published.[7]
Ask the plan: Point32Health provider services.
No — MassHealth discontinued the Tufts Health Together MCO product effective January 1, 2026 (All Provider Bulletin 410). Only the two ACPPs, with Cambridge Health Alliance and with UMass Memorial Health, remain active.
Yes, through its two active ACPPs — the MassHealth EPSDT benefit with no published hour caps, reviewed by Point32Health's internal UM against its own medical-necessity guideline (InterQual + SmartSheets; new MNG effective 1/1/2026).
No — as of the October 2025 update, members use Point32Health's own updated ABA PA form, submitted through the MHK portal with the form uploaded or faxed to 888-977-0776 (the Together fax printed on the form). Even the initial evaluation is a PA request: pages 1-3 with the child's IEP and the comprehensive diagnostic evaluation. It's the one MassHealth plan family where the standard form doesn't apply.
Per Point32Health's February 2026 provider update, all contracted ABA providers must be accredited by a nationally recognized accrediting body specializing in ABA, across Harvard Pilgrim and Tufts Health Plan products. Center-based providers in Massachusetts and Rhode Island must be accredited by January 1, 2027; all other providers by January 1, 2028 — treat it as a contracting prerequisite.
90 calendar days from the date of service for first-time claims. As secondary payer, 60 days from the primary carrier’s EOP. Payment disputes are due within 60 days of the EOP that denied the claim, and late-filing denials are reconsidered only for the MassHealth exceptions (retroactive enrollment, late notice of eligibility, or an exception MassHealth authorized).
Point32Health issues a weekly explanation of payment through Payspan Health. Its claims chapter publishes no clean-claim payment day count and no weekly submission cutoff.
Yes. Its ABA guideline lists H0031 (assessment and treatment planning by a BCBA) with 97151, 97153, 97154, 97155, 97156 and 97157, all requiring prior authorization. H0032, H2012 and H2019 were removed in 2023.
Yes. Its guideline requires progress documented by behavioral graphs showing change from baseline, plus daily session notes, and an updated treatment plan at least every six months with data on change from baseline across goals.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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