Office Managers Meeting. Watertown, MA June 26, 2018

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1 Office Managers Meeting Watertown, MA June 26, 2018

2 Discussion Topics Product Overviews Plan Identification Provider Resource Center Provider Website Navigation Online Tools for Providers Secure Provider Website Provider News and Training Provider Resources and Education

Division and Product Organization To optimize use of our online resources, you must identify and select the Tufts Health Plan division in which the member is enrolled: Commercial Medicare Tufts

3 Division and Product Organization To optimize use of our online resources, you must identify and select the Tufts Health Plan division in which the member is enrolled: Commercial Medicare Tufts Health Plan Senior Care Options (SCO) Tufts Health Public Plans Refer to the Products Overview and Member ID Card Guide for assistance in determining the member s plan and the division under which the plan falls.

4 Tufts Health Freedom Plan and Tufts Health Plan Commercial Plans Commercial providers may see Tufts Health Freedom Plan members. Tufts Health Freedom Plan members will have a Tufts Health Freedom Plan member ID card, and Tufts Health Plan Commercial members will have a Tufts Health Plan member ID card. Reminder: Use Tufts Health Plan's secure Provider website to verify member eligibility, determine the member's plan type and access benefit information: tuftshealthplan.com/provider.

5 Tufts Health Plan s Tiered Plans A tiered plan is one in which providers are grouped into member cost-share levels, or tiers. Member cost share varies by tier, with Tier 1 requiring the smallest member cost share. Tufts Health Plan offers a variety of tiered plans. Some examples of tiered plans include: Your Choice Navigator by Tufts Health Plan TM Massachusetts Group Insurance Commission (GIC) Plans Navigator by Tufts Health Plan TM Tufts Health Plan Spirit Steward Employee Choice Lifespan Premier Choice Tufts Health Freedom Plan Note: Tiering methodology differs by plan type.

6 Limited Network Plans A limited-network plan provides access to a network that is a subset of Tufts Health Plan s standard network. These plans require that members receive all nonemergent covered services from providers who participate in the network specified by their particular plan type. Limited-network plans are designed to help lower costs while still providing the benefits and services that members need. Some examples of limited Network plan include: Tufts Health Plan Spirit Select Network Plans

7 GIC Navigator and Spirit Plan Updates For the GIC Navigator tier design, providers and hospitals will continue to be placed in one of three tiers. PCPs and specialists will continue to be tiered. Providers and hospitals falling under the same contracted provider system will be placed in the same tier. The GIC Spirit tier design applies only to those providers and hospitals who participate in the Spirit product. With this tier design, hospitals will continue to be placed in one of two tiers. All specialists will continue to be placed in one of three tiers. Note: PCPs and PCP/specialists are not tiered under the GIC Spirit plan design. Refer to GIC Navigator and Spirit Tiering Information on Tufts Health Plan s public Provider website to verify provider and hospital tier placement by product. tuftshealthplan.com/documents/providers/general/gic-tiering-info

8 Tufts Health Plan to Manage Behavioral Health Services for GIC Members Effective July 1, 2018, Tufts Health Plan will manage behavioral health services for GIC Navigator and Spirit plans. For dates of service on or after July 1, 2018, to process at the authorized level of benefits, Tufts Health Plan will require an outpatient treatment notification for GIC Navigator members seeking behavioral health and substance use disorder services. Providers must provide an initial notification for patients who are new to their practice or for existing patients whose behavioral health services were previously managed by Beacon Health Options. Notifications for both initial and additional visits can be submitted by: Logging in to the secure Provider website tuftshealthplan.com/provider Using the Interactive Voice Response (IVR) system by calling Note: Behavioral health outpatient notifications can be backdated up to 30 calendar days. GIC Navigator members may see any behavioral health provider participating in the Tufts Health Plan network. GIC Spirit members may see any behavioral health provider who participates in the Spirit network and outpatient treatment notification is not necessary.

9 Navigating Tufts Health Plan s Provider Website tuftshealthplan.com/provider

10 Navigating Tufts Health Plan s Website tuftshealthplan.com/provider Tufts Health Plan s Provider website has two distinct sections: Public Provider website Medical necessity guidelines Payment policies Pharmacy programs Provider manuals Training and education Secure Provider website (registration required) 1. Tufts Health Provider Connect (Tufts Health Public Plans only) 2. Tufts Health Plan Provider Portal (Commercial and Senior Products) Claims status inquiry Eligibility and benefits Referral inquiry and submission Inpatient notification request submission Online claim adjustments (now available for Senior Products)

Google Chrome Note: Internet Explorer is not

11 Recommended Browsers Tufts Health Plan recommends using the latest versions of one of the following Internet browsers for the public and secure Provider websites: Mozilla Firefox Google Chrome Note: Internet Explorer is not optimal for working on the public and secure Provider websites.

12 Select a Division To find the information that you need, identify which division of Tufts Health Plan your patient s plan is listed under. Tufts Health Plan Commercial plans, Tufts Medicare Preferred HMO, Tufts Health Plan SCO and Tufts Health Public Plans require separate provider agreements Accept patients with plans that are listed in the divisions with which you hold provider agreements. Always verify member eligibility. Check the member s ID card to determine the member s plan. Use the secure Provider website to verify the member s plan.

13 Secure Provider Website Login - Select a Division

14 NEW Secure Provider Website for Commercial and Senior Products

15 Claims Status Inquiry - Free Form Search You can search with any information related to the claims that you are looking for. For example, if you are looking for a claim from July. Just type July in to the search box, and claims associated with the month of July will be returned. You can search for multiple pieces of information at once. For example, you can enter many claim numbers returning multiple results. You can also enter multiple pieces of information related to a single claim in order to refine search results. When searching for multiple pieces of information at once, simply put a comma and/or space in between your search items.

16 Claims Adjustment

17 Provider Payment Dispute Overview Providers have the right to file a payment dispute if they disagree with a decision regarding the denial or compensation of a claim. The Online Claim Adjustment Tool on the secure Provider website is the primary means of submitting Commercial and Senior Products claim adjustment request and payment disputes. When submitting a payment dispute by mail, the Request for Claim Review Form, along with any supporting documentation, is required. The form can be found in the Forms section of the Resource Center at tuftshealthplan.com/provider. A separate dispute form must be submitted for each claim adjustment. All incomplete submissions will be returned. For complete information, refer to the Provider Payment Dispute Policy found in the Payment Policy section of the Resource Center on the public Provider website.

18 Tufts Health Public Plans

19 Tufts Health Public Plans Tufts Health Public Plans provide access to high-quality health care for Massachusetts and Rhode Island residents with low to moderate incomes. Plan offerings include: Tufts Health Direct Health Connector (A focused network plan for individuals and small groups) Tufts Health Together Includes MassHealth Plans, as well as the following Accountable Care Organization (ACO) Plans (Effective 3/1/18): Tufts Health Together with Atrius Health Tufts Health Together with BIDCO Tufts Health Together with Boston Children s ACO Tufts Health Together with CHA Tufts Health RITogether A RI Medicaid Plan (serving RIte Care and Rhody Health Partners members) Tufts Health Unify OneCare Plan (Medicare-Medicaid plan)

20 Tufts Health Public Plans Member ID Cards Plan name The blue stripe indicates a Tufts Health Public Plans product.

21 Tufts Health Together ACO Member ID Cards Each ACO plan includes unique features and special programs.

22 Tufts Health RITogether Tufts Health RITogether, our Rhode Island Medicaid plan, provides health insurance to eligible members of the state of Rhode Island. A separate provider agreement is needed for participation in the Tufts Health RITogether provider network.

23 Referrals PCP referral requirements apply to members in certain provider systems seeking nonemergent specialty services. Information about referrals can be found in Chapter 2 of the Tufts Health Public Plans Provider Manual:

Plans Payment Policies section in the Resource Center on the public Provider

24 Specialty Services Referral Requirement Payment Policy The Specialty Services Referral Requirement Payment Policy is located in the Tufts Public Plans Payment Policies section in the Resource Center on the public Provider website. The policy includes a list of services that do not require a PCP referral.

25 Tufts Health Public Plans - Referrals The chart below demonstrates the specialist referral policy applicable to Tufts Health Together MCO and ACPP plans:

26 Tufts Health Public Plans - Services That Require Prior Authorization Services from out-of-network providers Certain covered services Non-preferred in-network facilities, specialists and providers Daily home health care (HHC) services or for HHC extending beyond six months in duration Certain durable medical equipment (DME) Certain behavioral health services Certain drug authorizations Advanced radiology imaging services, interventional pain management spinal surgeries and management of joint surgeries

27 Tufts Health Public Plans - Prior Authorization Requests Submitting Prior Authorization Requests MedHOK Portal via Tufts Health Provider Connect (Tufts Health Together and Tufts Health Direct) Tufts Health Provider Connect (Tufts Health Unify) Fax a Standardized Prior Authorization Request Form to Verifying Prior Authorizations Ongoing status of a prior authorization: MedHOK Portal via Tufts Health Provider Connect Completed review decisions are available: Through the MedHOK Portal via Tufts Health Provider Connect NEHEN or NEHENNet

28 Claim Information 1. File claims through Tufts Health Provider Connect 1. File claims no later than 90 days after the date of service Submit claims using Tufts Health Provider Connect online or in paper by mailing them to: Tufts Health Plan P.O. Box 8115 Park Ridge, IL Check claim status or get remittance advice 2. Check claim status by going to Tufts Health Provider Connect. 3. File a request for claim review 3. File a request for a claim review no later than 60 days after you receive the explanation of Payment (EOP) You may find the Request for Claim Review form on our website in the Provider Resource Center.

29 Secure Provider Website Login - Tufts Health Public Plans

30 Tufts Health Provider Connect Tufts Health Provider Connect offers online self-service tools for Tufts Health Public Plans products. Tufts Health Public Plans products include Tufts Health Direct, Tufts Health RITogether, Tufts Health Together and Tufts Health Unify.

31 Tufts Health Provider Connect - thpprovider.healthtrioconnect.com

32 Tufts Health Provider Connect User Guide

33 MedHOK Provider Portal Submit inpatient notifications and outpatient authorization requests for Tufts Health Together and Tufts Health Direct Members online.

34 MedHOK Provider Portal User Guide Inpatient notifications and prior authorization requests for outpatient services, for Tufts Health Direct and Tufts Health Together plan members, should be entered in the MedHOK online tool through Tufts Health Provider Connect..

35 Provider Resource Center

36 Provider Resource Center - Payment Policies

37 Authorization Policy

38 Medical Necessity Guidelines Medical necessity guidelines are established and based on current literature review, including InterQual; consultation with practicing physicians in the Tufts Health Plan service area, who are medical experts in the particular field; the policies of government agencies, such as the U.S. Food and Drug Administration (FDA); and standards adopted by national accreditation organizations. Guidelines are revised and updated annually, or more frequently as new evidence becomes available that suggests needed revisions. Medical necessity guidelines and InterQual criteria are used in conjunction with the member s benefit plan document and in coordination with the provider recommending the service, drug, device or supply.

39 Medical Necessity Guidelines

40 Medical Necessity Guidelines (continued)

41 Find Pharmacy Information on the Provider Website Current information regarding tier changes, online formularies and descriptions of pharmacy management programs is available on the Pharmacy section at tuftshealthplan.com/provider/pharmacy.

42 Tufts Health Public Plans - Tufts Health Public Plans Massachusetts Provider Manual

43 Administrative Updates and 60-Day Notifications* *As published in the May 1, 2018 issue of Provider Update

44 Provider Update - One Newsletter for all Products Beginning with the August 1, 2018 issue, Tufts Health Plan will have one combined Provider Update newsletter for all products. The combined Provider Update will include 60-day notifications and other important business communications applicable to Commercial products, Senior Products and Tufts Health Public Plans products. Provider Update will continue to be released on the existing schedule: February 1, May 1, August 1 and November 1.

45 US Family Health Plan Billing Information When billing services for US Family Health Plan (USFHP) members, providers are reminded not to bill Medicare for services covered by USFHP. Medicare may be billed only for services not covered by USFHP, e.g., end-stage renal disease. For such instances, Medicare should be billed first, followed by USFHP. For a list of noncovered services, refer to the TRICARE Guidelines. USFHP cannot compensate for claims that have been billed to and compensated by Medicare. Providers must first reimburse Medicare for any previous payment made in error, and must then bill USFHP for compensation of those services. Any private health insurance, with the exception of Medicare Supplement plans, should be billed prior to billing USFHP. This includes federal and state employee insurances. Providers are reminded to check the member's ID card to identify USFHP members. For questions, call

46 Telehealth Services Through Teladoc Effective May 1, 2018, in collaboration with Teladoc, Tufts Health Plan offers telehealth services to members belonging to fully insured (and certain self-insured) Commercial groups (including Tufts Health Freedom Plan). Member eligibility varies by group. Providers may direct members to self-service channels to verify eligibility. Eligible members can access Teladoc through the Tufts Health Plan secure Member website, the Teladoc mobile app or by calling Teladoc at TELADOC ( ).

47 Update Your Practice Information Providers are reminded to notify Tufts Health Plan of any changes to their contact or panel information, such as a change to their ability to accept new patients, a change of street address or phone number, or any other change that affects their availability to patients. How to Update Your Information Commercial (including Tufts Health Freedom Plan products), Tufts Medicare Preferred HMO and Tufts Health Plan SCO Providers If your contact/panel information is not correct on the Find a Doctor search, please update it as soon as possible by completing the Standardized Provider Information Change Form or Tufts Health Plan s Provider Information Change Form, available in the Provider Forms section of the Resource Center, and returning it by fax or mail, as noted on the form. Tufts Health Public Plans Providers If your contact/panel information is not correct on the Find a Doctor search, please update it as soon as possible by completing the Provider Information Form for Medical Providers or for Behavioral Health Providers, available in the Provider Forms section of the Resource Center, and returning it by fax or mail, as noted on the form.

Register to Receive Provider Update by Email The registration form can be accessed on the public Provider website at tuftshealthplan.com/provider.

49 Register to Receive Provider Update by The registration form can be accessed on the public Provider website at tuftshealthplan.com/provider. Click "Register Your " below to complete and submit the short registration form. Note: This address will be used only for required notifications and other pertinent business communications. It will not change or grant login credentials to the secure Provider website.

50 Provider Update - tuftshealthplan.com/provider/news View changes that apply to Commercial products.

51 Provider Education and Training - Provider Resource Guides tuftshealthplan.com/provider/training/guides-and-resources

52 Provider Education and Training - Webinars tuftshealthplan.com/provider/training/webinars

53 Contact Information Provider Education: EDI Operations: ext or Technical Inquiries: , option 6 or network_tech@tufts-health.com Commercial and Senior Products Behavioral Health Department: Provider Call Centers: Tufts Health Plan Commercial Provider Services: Tufts Health Public Plans Provider Services (MA): Tufts Health Public Plans Provider Services (RI): Tufts Health Plan Medicare Preferred and Tufts Health Plan SCO Provider Relations:

Office Managers Meeting

Office Managers Meeting Watertown, MA and by Live Stream March 26, 2019 Discussion Topics Product Overviews Plan Identification Provider Resource Center Provider Website Navigation Online Tools for Providers