Last updated 6/14/2021: Rhode Island Commercial products continue to waive in-network referrals and behavioral health prior authorization requirements for certain services through July 9, 2021; Alternative submissions of clinical information for Behavioral Health providers and temporary rate increases per MassHealth Managed Care Entity Bulletin 55 are effective through July 15, 2021; Pharmacy policies for Commercial products, Tufts Health Direct and Tufts Health RITogether and Credentialing policies for all products effective through August 7, 2021

Coronavirus (COVID-19) Updates for Providers

During the COVID-19 Public Health Emergency (PHE), Tufts Health Plan has adapted policies and business operations to support members receiving care and to aid providers in ensuring patients can safely access the care they need. Tufts Health Plan continues to monitor and follow recommendations from the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), State Public Health Departments (Connecticut, New Hampshire, Massachusetts and Rhode Island) and other official sources on an ongoing basis.

As COVID-19 cases continue to fall and states lift emergency orders, Tufts Health Plan is returning to pre-COVID-19 operations and policies. This page contains the most up-to-date information about Tufts Health Plan's policies and coverage for all fully-insured and self-insured groups*, however, self-insured groups do have the option to opt-out of several of these policies during the PHE and those opt outs may not be specifically listed. As the PHE continues to develop, updates will be posted here. Please check back regularly.

Please note, the information posted here, including member cost sharing changes, may differ from what is reflected in the secure Provider portal. Refer to the Claims Guidelines section for additional information.

Effective Dates

Unless otherwise noted, all policies are effective beginning with dates of service on or after March 6, 2020. These policies have been put in place in connection with the COVID-19 crisis and are not intended to be permanent changes. For any policy without an end date listed or for which it states "until further notice," we continue to evaluate Tufts Health Plan policies with the state emergencies and other regulations in mind, and will aim to provide at least four week notice in advance of any termination of the policy. Coverage and policies for Tufts Health Commercial (including Tufts Health Freedom Plan and CareLinkSM ), Tufts Health Medicare Preferred HMO, Tufts Health Plan Senior Care Options (SCO), Tufts Health Public Plans (Tufts Health Direct, Tufts Health RITogether, Tufts Health Together – MassHealth MCO Plan and Accountable Care Partnership Plans [ACPPs], and Tufts Health Unify) members, unless otherwise specified, are as follows:

COVID-19 Vaccinations, Testing and Treatment

COVID-19 Vaccinations
Once a COVID-19 vaccine obtains Emergency Use Authorization (EUA) and becomes available to members, Tufts Health Plan will cover the vaccine in full. There will be no cost to members. Refer to the COVID-19 Vaccination Payment Policy and the Coronavirus (COVID-19) Vaccination Frequently Asked Questions (FAQs) for Providers for additional information.

Tufts Health Plan complies with federal and state guidelines for vaccines. Refer to the DPH for Massachusetts, Rhode Island, and New Hampshire for information on vaccines.
COVID-19 Diagnostic Testing - Effective until further notice

The following applies to all Tufts Health Plan products:

  • Tufts Health Plan will pay 100% of the allowed amount for medically necessary testing (including, but not limited to radiology and lab tests). Click here for a list of procedure codes.
  • There will be no member cost sharing (i.e., no copays, deductible, or coinsurance) for viral and antibody testing. Providers should not collect a copay from members.
  • Testing for COVID-19 is covered when ordered or referred by a physician or appropriately licensed health care professional.
    • Tests self-ordered by members, including tests ordered through an online self-completed questionnaire, are not covered for reimbursement.
    • At home viral tests are not covered unless orderd by a physician or attending provider.
  • FDA authorized antibody testing for COVID-19 is covered only when it has been determined by a provider who has performed an individualized clinical assessment to be medically necessary to make decisions about a member's care in accordance with current CDC and state public health department guidelines, which are being continuously updated.
  • Testing is not covered if conducted solely for return-to-work or return-to-school purposes,  for public health surveillance, or for any other purpose not primarily intended for individualized diagnosis or treatment.
    • When performing any such tests, including non-diagnostic or occupational tests for return-to-work scenarios, providers should bill the appropriate laboratory code following our existing billing guidelines (e.g U0002) and use the diagnosis code.
  • Testing for asymptomatic members, including those with no known or suspected exposure to COVID-19, is covered when being admitted to a health care facility or when it has been determined by a provider who has performed an individualized clinical assessment to be medically necessary to make decisions about a member's care in accordance with current CDC and state public health department guidelines, which are being continuously updated.
  • Members are encouraged to see in-network providers, whenever possible. However, this policy applies to in-network and out-of-network (OON) providers.
COVID-19 Treatment - Effective as outlined below

The following applies to all Tufts Health Plan products:

  • Tufts Health Plan will reimburse providers for treatment according to covered benefits in our plans for those members positively diagnosed with COVID-19. Note: Per CMS, Senior Products and Tufts Health Unify providers on an IPPS-DRG payment will receive add-on payments for the treatment of COVID-19.
  • Tufts Health Plan will waive member cost share, including copays, for COVID-19 treatment when ICD-10 code U07.1 is present, in any position, on an Inpatient Facility claim and when ICD-10 code U07.1, Z03.818 or Z20.822 is present on an Outpatient Facility or Professional claim until August 6, 2021. Effective for dates of service on or after August 7, 2021, Tufts Health Plan will reinstate cost share for Rhode Island Commercial products and Tufts Medicare Preferred HMO. Note: For Professional claims, when one of the codes noted above is billed, member cost sharing is waived for only the service lines related to COVID-19 testing/treatment.
    • ICD-10 code U07.1 was developed by the World Health Organization (WHO) and is intended to be sequenced first followed by the appropriate codes for associated manifestations when COVID-19 meets the definition of principal or first-listed diagnosis. However, if COVID-19 does not meet the definition of principal or first-listed diagnosis (e.g. when it develops after admission), then code U07.1 should be used as a secondary diagnosis. For further guidance, please refer to the official ICD-10-CM guidelines for coding encounters related to the COVID-19 coronavirus outbreak.
    • Prior to April 1, 2020, B97.29 was accepted as a positive diagnosis for COVID-19. For discharge/dates of service on or after September 1, 2020 this code is not accepted as a positive diagnosis for COVID-19.
  • Monoclonal antibody treatment (bamlamivimab) is covered (without utilization management) in conjunction with etesevimab (Q0245, M2045) for the treatment of mild to moderate COVID-19 in adult and pediatric patients with positive COVID-19 test results who are at high risk for progressing to severe COVID-19 and/or hospitalization. Treatment is administered in the  outpatient setting. Due to the FDA's revocation of bamlamivimab when used as a stand-alone treatment for COVID-19, effective for dates of service on or after April 16, 2021, bamlamivimab is not covered when administered alone (Q0239, M0239).
    • Senior Products member claims should be submitted to Medicare Administrative Contractors (MACs).
    • Tufts Health Commercial and Tufts Health Public Plans products follow the standard claims submission processes.
  • Members are encouraged to see in-network providers, whenever possible. However, this policy applies to in-network and out-of-network (OON) providers.

Telehealth/Telemedicine

Temporary COVID-19 Telehealth Payment Policy

Refer to the Temporary COVID-19 Telehealth Payment Policy for the following:

Note: For dates of service after July 20, 2020, pre-COVID coverage policies and benefits (including applicable cost share) apply for out-of-network (OON) telemedicine.

Referrals and Out-of-Network Authorizations

In-Network Referral Policies – Effective as outlined below
Tufts Health Plan is waiving referral requirements for all in-network care, regardless of diagnosis, for all Tufts Health Plan products, with the exception of Tufts Health Freedom Plan.

This temporary referral policy applies to all fully-insured and self-insured groups*, however, self-insured groups do have the option to opt-out and those opt outs may not be specifically listed. To confirm referral opt outs for self-insured groups, contact Provider Services.

Referral requiresments will be reinstated for all products as outlined below:
  • Massachusetts Commercial Products: Effective for dates of service on or after July 1, 2021
  • Rhode Island Commercial Products: Effective for dates of service on or after July 9, 2021
  • Tufts Health Together: Effective for dates of service on or after August 7, 2021
  • Senior Products and Tufts Health Unify: Upon the end of the federal PHE
Note: As a reminder, Tufts Health RITogether and Tufts Health Direct does not require referrals. For more information, refer to the Referral, Prior Authorization and Notification Policy.
Out-of-Network Authorization Policies for COVID-19 Services – Effective as outlined below
Effective for dates of service on or after August 7, 2021, if a member's plan requires a referral or authorization to received out-of-network (OON) services, Tufts Health Plan is reinstating such requirements for the OON services listed below when related to a COVID-19 diagnosis for all plans with the exception of those in Massachusetts:
  • Inpatient care
  • Post-acute care, including inpatient rehab, skilled nursing facilities, long-term acute care (LTAC), and/or home care following an inpatient admission
  • Primary care or outpatient behavioral health services
  • Urgent/emergent services

Utilization Management

Prior Authorization Flexibility for the Diagnosis and Treatment of COVID-19 – Effective as outlined below
Prior authorization is not required, including for transfers to post-acute non-hospital facilities and for home health care, for the diagnoses and treatments related to COVID-19 or known or suspected of having a COVID-19 contraction. Note: Effective for dates of service on or after August 7, 2021, Tufts Health Plan will reinstate prior authorization requirements, as applicable, for diagnoses and treatments related to COVID-19 or suspected of having COVID-19 contractions for Tufts Health Freedom Plan, Rhode Island Commercial plans, Tufts Health RITogether and Senior Products plans. For members of Massachusetts plans, prior authorization will continue to be waived.

As a reminder, urgent/emergent admissions are never subject to prior authorization.

Note: Refer to the In Person, COVID-19 Treatment section above for ICD-10 codes to be present for the diagnosis and treatment of COVID-19.
Prior Authorization Guidelines – Effective as outlined below
Tufts Health Plan has reinstated prior authorization requirements for the following services, which apply to all diagnoses, except for a COVID-19 diagnosis, for which specific guidance is outlined above:
 
  • Hospice services. Refer to the Hospice Services Payment Policy for Commercial, Senior Products or Tufts Health Public Plans for additional information.
  • Elective inpatient treatment or outpatient scheduled surgeries or admissions to acute care hospitals or mental health hospitals. 
Effective for dates of service on or after August 7, 2021, Tufts Health Plan is reinstating prior authorization requirements for non-hospital locations for post-acute care (i.e. inpatient rehab, LTAC, skilled nursing facilities and home care), including following an inpatient hospital admission for Commercial Products, Tufts Health Direct, Tufts Health RITogether and Tufts Health Medicare Preferred HMO.

As a reminder, urgent/emergent admissions are never subject to prior authorization.
 

Behavioral Health Services

Effective for dates of service on or after June 1, 2021, prior authorization and notification is reinstated for the following behavioral health services for Massachusetts products:
  • Applied Behavioral Analysis (ABA) for all Massachusetts products
  • Children’s Behavioral Health Initiative (CBHI) for Tufts Health Together
  • Behavioral Health for Children and Adolescents (BHCA) for Massachusetts Commercial products
Unless otherwise extended by state orders, effective for dates of service on or after July 9, 2021, prior authorization and notification is reinstated for the following behavioral health services for Rhode Island products:
  • Applied Behavioral Analysis (ABA) for all Rhode Island products
  • Home-Based Therapeutic Services (HBTS) for Tufts Health RITogether
  • Psychology/Neuropsychology testing and rTMS for Rhode Island Commercial products
Note: Providers are still responsible for confirming the service is covered by the individual treatment plan and the member meets medically necessary criteria for the service.
Inpatient Notification and Concurrent Review
  • Notification is required within 2 business days after the date of admission for all diagnoses and are not specific to a COVID-19 diagnosis.
  • Concurrent review requirements are reinstated for all inpatient treatment (including inpatient hospice services), including behavioral health admissions at acute care hospitals or mental health hospitals. Pre-COVID processes should be followed.
Note: Tufts Health Plan remains available to assist with discharge planning for all admissions and reserves the right to retroactively review services for medical necessity.

Claims and Billing Guidelines

Providers should contact their contract manager to request a rate for medically necessary lab testing provided by an external laboratory in accorance with the MA DOI Bulletin 2020-25.

Claims Guidelines
Tufts Health Plan is informed when CMS and state insurance agencies issue new billing and reimbursement guidelines in response to the PHE. These guidelines are reviewed by Tufts Health Plan and implemented, as appropriate. Providers should not  await billing instructions from Tufts Health Plan.

Providers should follow guidelines on this page for dates of services listed during the PHE and continue to submit claims as they currently do. For all other billing guidelines, refer to the Professional Services and Facilities Payment Policy and the benefit-specific payment policies located in the Provider Resource Center.

Unless otherwise stated, Tufts Health Plan follows industry standard coding guidelines. Refer to current coding guidelines for a complete list of ICD, CPT/HCPCS, revenue codes, modifiers and their usage.

Note: Providers may bill inpatient for services provided at alternative inpatient sites.
Billing by Certified Registered Nurse Anesthetists - Effective until further notice
The following applies to all Tufts Health Plan products:
  • Certified registered nurse anesthetists (CRNA) are not required to include the supervising physician information on claims. Note: Tufts Health Plan will continue to compensate for medically necessary CRNA services.
  • Anesthesia claims should be billed with the appropriate procedure code, modifier and applicable time units, as described in the Anesthesia Payment Policies for Commercial and Senior Products and Tufts Health Public Plans.
  • Tufts Health Plan defers to providers to determine whether physician supervision is required under the laws of the state in which they practice and/or hospital policies.
Medicare Advantage Reimbursement - Effective through December 31, 2021
CMS has extended the suspension of the sequestration payment reduction through December 31, 2021. As such, Tufts Health Plan has implemented this CMS requirement and suspended the reimbursement reductions for Medicare Advantage hospital rates and professional rates for the same time period for acute care hospitals, clinicians, physicians and PCPs. This applies to Tufts Medicare Preferred, Senior Care Options, and Tufts Health Unify.

Other Benefit Information

Behavioral Health - Effective through July 15, 2021

Department of Mental Health (DMH) Tier 1 and Tier 2 Hospital Inpatient Notification Process

Per MassHealth Managed Care Entity (MCE) Bulletin 55, MassHealth requires Tufts Health Plan to temporarily increase rates for DMH designated Tier 1  and Tier 2  hospitals that have admitted COVID-19 positive Medicaid members through July 15, 2021. In order to administer this payment increase in accordance with the Bulletin, Tufts Health Plan requires DMH designated Tier 1 and Tier 2 hospitals to have completed the Bulletin 55 Provider Attestation form and send back to Tufts Health Plan.  In addition, Tier 1 and 2 providers must complete the Behavioral Health Services Inpatient Notification Form  when admitting a COVID-19 positive Tufts Health Together MCO or ACO member, or when treating a Tufts Health Together member that has become COVID-19 positive within 96 hours of admission. Refer to the form for submission instructions.

Submitting Clinical Information

Behavioral Health providers that do not have fax capabilities can email any clinical information to the appropriate Tufts Health Plan email address through July 15, 2021, as outlined below: In the email subject line, include the product name and type of service you are emailing information about.
Pharmacy - as outlined below
Commercial Products, Tufts Health Direct and Tufts Health RITogether
The following pharmacy polieis are in effect until August 7, 2021:
  • Tufts Health Plan will waive the refill limitation one-time to allow for early refills of a medication prescription prior to the expiration date, including specialty pharmaceuticals. Controlled substances are excluded from this policy.
  • Maintenance medications may be refilled for up to a 90-day supply, assuming the days supply is available based on the unused portion of the prescription.
Tufts Health Together
Senior Products and Tufts Health Unify
  • Tufts Health Plan allows early refills of a medication prescription prior to the expiration date, including specialty pharmaceuticals. Controlled substances are excluded from this policy.
  • Maintenance medications may be refilled for up to a 90-day supply, assuming the days supply is available based on the unused portion of the prescription.

Tips for Prescribers

For information for members on Warfarin that require international normalized ratio (INR) testing, click here.
DME, Medical Supplies and Home Health Services
In accordance with MassHealth MCE Bulletin 39, a member’s physician, nurse practitioner, physician assistant or clinical nurse specialist may:
  • Prescribe or write letters of medical necessity for DMEs and oxygen and respiratory equipment, and
  • Order home health services and establish, review, certify and recertify a member’s plan of care.

Personal Protective Equipment (PPE)

CPT code 99072 is designed for providers to report expenses incurred during a PHE, including PPE, cleaning supplies and additional clinical staff time. This code is non-reimbursable for all Tufts Health Plan products.

Credentialing

Credentialing of New Practitioners - Effective until August 7, 2021

The following policies for practitioners seeking to provide services during the PHE only are in effect until August 7, 2021:

  • Practitioners seeking to provide care during the PHE only, but do not seek to join any Tufts Health Plan network on a more permanent basis, should complete the COVID-19 Deployment Only Enrollment Roster and submit to: Provider_Information_Dept@tufts-health.com for Commercial (including Tufts Health Freedom Plan), Tufts Medicare Preferred HMO, and Tufts Health Plan Senior Care Options (SCO) networks and Provider_Data_Request@tufts-health.com for Tufts Health Public Plans.
  • Include “COVID-19 Enrollment Only” in the subject line of the email containing the completed form
  • Examples of such practitioners include:
    • Retirees granted temporary licensure in order to work during the PHE
    • Recent medical student graduates who may be granted temporary licensure who are working in a hospital or facility during the PHE and have not begun their residency programs
    • Clinical fellows and clinical researchers who have been granted temporary privileges to provide care in the facility setting
    • Any out-of-network practitioners granted a temporary license to provide services in a state where Tufts Health Plan serves, and not typically their home practice state in order to work during the PHE.  Note: This category of practitioner will need to have verifications completed, including inquiry about 1135-based licensure waivers from CMS, if applicable
Practitioners who seek to join Tufts Health Plan networks on a more permanent basis should follow the usual contracting and credentialing processes. Refer to the Credentialing and Contracting Overview for additional information. The Tufts Health Plan Credentialing Department will make every effort to expedite the credentialing process.

If you have any questions regarding expedited credentialing or provisional credentialing, please contact Tufts_Health_Plan_Credentialing_Department@tufts-health.com. Providers may also refer to the Frequently Asked Questions to Tufts Health Plan’s Credentialing Department.
 

More Information

COVID-19 Policies History
  • June 14, 2021: Rhode Island Commercial products continue to waive in-network referrals and behavioral health prior authorizations for certain services through July 9, 2021; Alternative submission of clinical information for Behavioral Health services effective through July 15, 2021; Pharmacy policies for Commercial products, Tufts Health Direct and Tufts Health RITogether and Credentialing policies for all products effective through August 7, 2021
  • June 10, 2021: Reinstatement of the following policies, effective for dates of service on or after August 7, 2021: referrals for Tufts Health Together, any required authorizations for COVID-19 treatment, including for out-of-network providers, for all products with the exception of Massachusetts plans, any required prior authorization for non-hospital locations for post-acute care for Commercial Products, Tufts Health Direct, Tufts Health RITogether, and Tufts Health Medicare Preferred HMO
  • June 7, 2021: Reinstating cost share for COVID-19 treatments for Rhode Island Commercial products and Tufts Medicare Preferred HMO, effective for dates of service on or after August 7, 2021
  • June 1, 2021: Reinstatement of referral requirements for all Commercial products; effective for dates of service on or after July 1, 2021
  • May 13, 2021: Prior authorization is no longer required for chloroquine and hydroxychlorine, effective for dates of service on or after June 1, 2021;
  • May 5, 2021: Reinstatement of prior authorization for behavioral health services in Massachusetts, effective June 1, 2021 and for Rhode Island products, effective July 1, 2021, unless otherwise extended by state orders
  • April 20, 2021: Bamlanivimab is not covered when administered alone, effective for dates of service on or after April 16, 2021
  • March 19, 2021: Revised COVID-19 testing requirements; prior authorization and notification is required for psych/neuropsych testing and rTMS for Rhode Island Commercial products; effective for dates of service on or after June 1, 2021
  • March 2, 2021: Inpatient notification is required within 2 business days of admissions, prior authorization is required for non-hospital locations for post-acute care and hospice services, effective for dates of service on or after April 1, 2021
  • February 3, 2021: COVID-19 Treatment cost share is waived when the appropriate diagnoses are listed on the claim.
  • January 26, 2021: Tufts Health Plan will provide reasonable extensions of timeframes for provider audits of hospital claims through March 31, 2021
  • December 11, 2020: Revised telehealth billing for Tufts Health RITogether
  • November 30, 2021: Coverage for monoclonal antibody treatment; CPT code 99072 in non-reimbursable
  • November 6, 2020: Reinstatement of copays for non-COVID-19 related telehealth services, effective for dates of service on or after January 1, 2021
  • September 30, 2020: Revised policy effective dates for concurrent review (December 31, 2020), prior authorization is suspended for any inpatient treatment or outpatient scheduled surgeries or admissions to acute care hospitals or mental health hospitals for Massachusetts Commercial Products and Tufts Health Direct (December 31, 2020), provider appeals (effective through December 31, 2020) and audits for hospital claims (Orthonet program resumes October 1, 2020; Forensic Review will resume January 1, 2021)
  • September 22, 2020: Revised telehealth billing guidelines
  • August 17, 2020: Added additional CPT codes for COVID-19 testing and updated guidance for B97.29 and U07.1
  • August 12, 2020: Testing coverage for asymptomatic members; OON authorization policies for COVID-19 services
  • August 6, 2020: Rapid testing is covered when determined to be medically necessary
  • July 24, 2020: Clarified concurrent review policies effective through September 30, 2020
  • July 16: 2020: Timeframe for filing appeals is extended up to 90 days, upon request through September 30, 2020; added codes for COVID-19 testing; clarified COVID-19 testing policies and added new COVID-19 testing codes
  • July 10, 2020: Reinstating cost share and coverage for OON services, unrelated to COVID-19 diagnosis or treatment, standard claims submissions and timely filing policies, effective for dates of service on or after July 20, 2020; ART policy flexibilities and pre-payment billing review and post payment billing audit changes effective until July 20, 2020 concurrent review suspension for post-acute and urgent/emergent admissions through September 30, 2020
  • June 29, 2020: Updated billing guidance for behavioral health telehealth claims
  • June 22, 2020: Providers have 180 from date of determination to request a peer-to-peer (Orthonet) and 90 days from the date of determination to appeal (Forensic Review)
  • June 17, 2020: Added language clarifying home testing kits, or other tests self-ordered by members, are not covered for reimbursement
  • June 12, 2020: Added billing guidelines for Adult Day Health Providers for Tufts Health Unify and Senior Care Options
  • June 10, 2020: Reinstatement of concurrent review for dates of service on or after July 20, 2020; reinstatement of prior authorization for elective non-COVID-19 admissions for dates of service on or after July 20, 2020
  • April 21, 2020: Suspending the reimbursement reduction for Medicare Advantage
  • April 13, 2020: Member plans requiring referrals or authorizations for out-of-network (OON) is waived for certain services; added credentialing content; extending ART cycles
  • April 10, 2020: Timeframe for filing appeals has been extended by 90 days from standard appeals timelines; added prepayment billing review and post-payment billing audit content, effective through June 1, 2020; added policy for assisted reproductive technology (ART)
  • March 27, 2020: Added coverage for hydroxychloroquine
  • March 24, 2020: Added POS and modifiers for telehealth billing
  • March 18, 2020: COVID-19 Updates for Providers page created; included COVID-19 testing and treatment policies; telehealth policies; pharmacy and authorization flexibilities

 

*The above applies to all fully-insured and self-insured groups. Self-insured groups do have the option to opt-out of several of these policies but must do so in writing. Because Uniformed Services Family Health Plan (USFHP) is subject to separate federal requirements, the above policies do not apply to USFHP with the exception of the policies regarding COVID-19 Diagnostic Treatment and Inpatient Notification Flexibility. Please refer to the USFHP provider portal for information regarding telemedicine billing procedures.

The above policies will be revisited on a continuing basis.

Note: Providers should follow these guidelines for the dates of services listed during the COVID-19 emergency. For all other billing guidelines, refer to the Professional Services and Facilities Payment Policy  and the benefit-specific payment policies located in the Provider Resource Center.