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 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 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.
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.
Navigating Tufts Health Plan s Provider Website tuftshealthplan.com/provider
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.
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) Tufts Health Provider Connect (Tufts Health Public Plans only) 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
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.
Secure Provider Website Login - Select a Division
Submit Transactions Electronically Using Tufts Health Plan s Secure Online Self-Service Channels Electronic self-service tools enable providers to submit transactions and/or access information related to claims submission, claims status, referrals, prior authorizations, electronic remittance advice, member eligibility, panel information, etc. Commercial and Senior Products Secure Provider website: Commercial products (including Tufts Health Freedom Plan) Senior Products Tufts Health Public Plans Products Tufts Health Provider Connect: Tufts Health Public Plans products Not Yet Registered? Information on how to register for secure access is available on Tufts Health Plan s public Provider website
Secure Provider Website for Commercial and Senior Products
Claims Status Inquiry - Free Form Search You can search with any information related to the claims that you are looking for. If you are looking for a claim from July, 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. 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, put a comma and/or space in between your search items.
Claims Adjustment -Commercial or Senior Products
Provider Payment Dispute Overview -Commercial or Senior Products 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.
Submitting Payment Disputes By Mail -Commercial or Senior Products A separate Request for Claim Review Form, along with any supporting documentation, is required for each claim adjustment. Make sure to list a valid claim number, Tufts Health Plan message code and indicate the appropriate review type on the form.
Tufts Health Public Plans
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). A separate provider agreement is needed for participation in the Tufts Health RITogether provider network. Tufts Health Unify OneCare Plan (Medicare-Medicaid plan)
Tufts Health Together ACO Member ID Cards Each ACO plan includes unique features and special programs.
Tufts Health Public Plans Referral Information 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:
Specialty Services Payment Policy The Specialty Services 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.
Tufts Health Public Plans - Referrals The chart below demonstrates the specialist referral policy applicable to Tufts Health Together MCO and ACPP plans:
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
Tufts Health Public Plans - Submitting Prior Authorization Requests Online Submitting Prior Authorization Requests MedHOK Portal (accessed via Tufts Health Provider Connect) Tufts Health Together Tufts Health Direct Tufts Health Provider Connect Tufts Health Unify Fax a Standardized Prior Authorization Request Form to 888.415.9055 Verifying Prior Authorizations Ongoing status of a prior authorization: MedHOK Portal via Tufts Health Provider Connect Completed review decisions are available: MedHOK Portal
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 on paper by mailing them to: Tufts Health Plan P.O. Box 8115 Park Ridge, IL 60068-8115 2. Check claim status by going to Tufts Health Provider Connect. 2. Check claim status or get remittance advice 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. Mail requests forms to: Tufts Health Public Plans Provider Payment Disputes P.O. Box 9194 Watertown, MA 02471-9194
Secure Provider Website Login - Tufts Health Public Plans
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.
Tufts Health Provider Connect User Guide
MedHOK Provider Portal Submit inpatient notifications and outpatient authorization requests for Tufts Health Together and Tufts Health Direct Members online.
MedHOK Request and view outpatient prior authorization requests for Tufts Health Together and Tufts Health Direct Members online. Request medical prior authorization by clicking here. View authorizations by clicking here.
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..
Provider Resource Center
Provider Resource Center - Payment Policies
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.
Medical Necessity Guidelines
Tufts Health Public Plans - Tufts Health Public Plans Massachusetts Provider Manual
Administrative Updates and 60-Day Notifications* *As published in the February 1, 2019 issue of Provider Update
Provider Update - One Newsletter for all Products Tufts Health Plan now has one combined Provider Update newsletter for all products. The combined Provider Update includes 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.
Register to Receive Provider Update by Email The registration form can be accessed on the public Provider website at tuftshealthplan.com/provider. Click "Register Your Email" below to complete and submit the short registration form. Note: This email 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.
Oral Enteral Formulas Covered Under Medical Benefit -Commercial Tufts Health Plan now covers oral enteral formulas under the medical benefit only. Members must obtain them through a contracted durable medical equipment (DME) supplier. Member cost share for each supply of oral enteral formula dispensed by a DME supplier. Ordering providers should send a formula prescription to a Tufts Health Plan-contracted DME formula supplier, who will send a prior authorization request to the Tufts Health Plan Precertification Department. Documented in the Medical Necessity Guidelines for Oral Formula: Massachusetts Products Durable Medical Equipment Payment Policy
Pharmacy Benefits and Programs -Formularies Current information regarding tier changes, online formularies and descriptions of pharmacy management programs is available on the Pharmacy section at tuftshealthplan.com/provider.
Pharmacy Programs (Continued) -Definitions Noncovered Drugs (NC)-A list of drugs that Tufts Health Plan currently does not cover, often because safe, comparably effective, and cost effective alternatives are available. Providers can submit a request for coverage to Tufts Health Plan under the Medical Review Process. New-to-Market Evaluation-All drugs must meet a series of high standards before we include them in our formulary. Prior Authorization-Tufts Health Plan requires prior authorization for certain drugs, particularly those that are new to market. Even after going through the Tufts Health Plan new to market evaluation process, we evaluate the medications to measure uses and effects. Providers must submit a request for prescriptions for drugs on the prior authorization requirement list before we will approve that drug for a member. Quantity Limitations-Developed to monitor safety and help control the cost of prescription drugs for our members. Our Quantity Limitations Program limits the quantity of a drug a member can receive in a given time period.
Pharmacy Programs (Continued) -Definitions Designated Specialty Pharmacy Program-Has designated specialty pharmacies to supply a select number of medications used in the treatment of complex diseases. Medications include, but are not limited to, those used in the treatment of infertility, multiple sclerosis, hemophilia, hepatitis C and growth hormone deficiency. Step Therapy Prior Authorization (STPA)-Encourages the use of therapies that should be tried first, before other treatments are covered, based on clinical practice guidelines and cost-effectiveness. Medications on Step 1 are usually covered without authorization. Medications on Step 2 or higher are automatically authorized at the point-of-sale if the patient has taken the required prerequisite drugs. If the provider prescribes a medication on a higher step, and the patient has not yet taken the required medication(s) on a lower step, or if the patient is a new Tufts Health Plan member and does not have any prescription drug claims history, we will consider coverage of the medication only if the provider submits a request for coverage to Tufts Health Plan.
Pharmacy Prior Authorization -Commercial
Tufts Medicare Preferred HMO plans and the Tufts Health Plan Senior Care Options (SCO) Plan earned a 5 out of 5 star rating from Medicare! For additional information and rating details visit: tuftsmedicarepreferred.org/medicare-star-ratings
New Hearing Aid Benefit January 1, 2019 -Tufts Medicare Preferred HMO Tufts Medicare Preferred HMO members* are eligible for a new hearing aid benefit through Hearing Care Solutions. Members must see a provider participating in the Hearing Care Solutions network. Member eligibility and benefit specifics should be verified prior to initiating services by logging on to the secure Tufts Health Plan Provider website. This is documented in the Audiology Professional Payment Policy. To learn more about this benefit or to join the Hearing Care Solutions provider network: Contact Hearing Care Solutions at 866.344.7756. *This benefit applies only to individual policy holders and does not apply to employer group coverage.
Cultural Competency Training -Tufts Health Public Plans Providers Cultural Competency Training status can be reflected in our online provider directory. Based in part on CMS s requirements for Tufts Health RITogether Tufts Health Together (MCO and ACPP plans) Tufts Health Unify Providers can complete the Cultural Competency Attestation form on our public Provider website. Cultural Competence* describes the ability of systems and health care professionals to provide high-quality care to patients with diverse values, beliefs and behaviors. This includes tailoring delivery to meet each individual s social, cultural and linguistic needs. *Definition from The Commonwealth Fund s Cultural Competence in Health Care Report
Tufts Health Public Plans Disease Management Programs Designed to assist with coordination and care for members with certain chronic conditions: Asthma Diabetes COPD and/or congestive heart failure Available to members of Tufts Health Direct Tufts Health Together (MassHealth MCO Plan and Accountable Care Partnership Plans [ACPPs]) Refer to Tufts Health Public Plans Disease Management Located in the Condition Management section of public Provider website: tuftshealthplan.com/provider/condition-management/tufts-healthpublic-plans-condition-management/disease-management-programs
MassHealth Outpatient Care Coordination Training Module Tufts Health Plan is sharing its online training module with its provider network. An Interactive Resource for Coordinating Care for MassHealth Youth in Outpatient Therapy Provides outpatient providers with information regarding their responsibility to coordinate care for members of Tufts Health Together MassHealth MCO Plan and Accountable Care Partnership Plans (ACPPs) who are under 21 years of age http://www.cbhknowledge.center/op-online-trainingresource/
Administratively Necessary Days -Tufts Health Together For dates of service on or after April 1, 2019, revenue code 0169 must be used to report Administratively Necessary Days (AND) services. Applies only to: Tufts Health Together MassHealth MCP Plan and Accountable Care partnership Plans (ACCPS) Documented in payment policies: Diagnosis Related Group (DRG) Inpatient Facility Non-Diagnosis Related Group Inpatient Facility
Behavioral Health Screening Survey -Tufts Health Together Tufts Health Plan looks to PCPs to provide feedback on their behavioral health screening practices for: Tufts Health Together MassHealth MCO Plan and Accountable Care Partnership Plans (ACPPs) members. Improve behavioral health screening for members Address barriers PCPs face when it comes to administering these screenings Providers who complete this survey by May 1, 2019 will be entered in a drawing to win one of three $100 Amazon gift cards.
MassHealth Members in DCF Care -Tufts Health Together Individuals in the care of the Massachusetts Department of Children and Families (DCF), or who qualify only for the plans listed below are not subject to the PCP exclusivity required by Tufts Health Together MassHealth MCP Plan and Accountable Care Partnership Plans (ACPPs). MassHealth Limited Children s Medical Security Plan (CMSP) Health Safety Net Providers contracted with Tufts Health Together-MassHealth MCP Plan and ACPPs must see these individuals upon request and submit claims for these services to MassHealth. Contact MassHealth directly with questions.
Claims and Enrollment System Migration -Tufts Health Public Plans Tufts Health Plan is migrating its Massachusetts-based Tufts Health Public Plans business to a new system to support claims adjudication and enrollment process. Tufts Health Direct Tufts Health Together MassHealth MCO Plan and ACPPs Tufts Health Unify As part of the migration, providers will receive two separate payments, depending upon the system on which their claims are processed. Provider News section of public Provider website will be updated. System migration questions should be directed to Tufts Health Public Plans Provider Services at 888.257.1985
Provider Education and Training - Provider Resource Guides tuftshealthplan.com/provider/training/guides-and-resources
Provider Training and Education - tuftshealthplan.com/provider/training
Contact Information Provider Call Centers: Tufts Health Plan Commercial Provider Services: 888.884.2404 Tufts Health Public Plans Provider Services (MA): 888.257.1985 Tufts Health Public Plans Provider Services (RI): 844.301.4093 Tufts Health Plan Medicare Preferred and Tufts Health Plan SCO Provider Relations: 800.279.9022 Commercial and Senior Products Behavioral Health Department: 800.208.9565 EDI Operations: 888.880.8699 ext. 54042 or EDI_Operations@tufts-health.com Technical Inquiries: 888.884.2404, option 6 or network_tech@tufts-health.com Provider Education: provider_education@tufts-health.com