Last updated 05/09/22: Additional changes have been made to the over-the-counter COVID-19 testing for Tufts Medicare Preferred HMO members
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 their efforts to provide patients with safe access to the care they need.
As states lift PHE orders, Tufts Health Plan is returning to many pre-pandemic operations and policies. Refer to the resources below for the most up-to-date information about Tufts Health Plan's policies and coverage. For any product not specifically stated within the PHE-related policies outlined below, the pre-pandemic policy applies.
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 applicable state PHE orders and other regulations in mind, and will aim to provide at least four weeks' notice in advance of any termination of the policy. Coverage and policies for Tufts Health Commercial (including 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:
Tufts Health Plan understands the urgency of getting vaccines administered swiftly and effectively and is committed to supporting providers in this important work. We are also conducting education and outreach to our members to educate them about the known safety of COVID-19 vaccines and the importance of getting vaccinated.
The federal government has purchased the vaccine and is supplying it to vaccinators. Providers will receive the vaccines from the state and/or federal health agencies.
Tufts Health Plan complies with federal and state guidelines for vaccines. Refer to the applicable Department of Public Health (DPH) for Massachusetts, Rhode Island, and New Hampshire for information on vaccines.
COVID-19 Vaccination Cost Share
Referrals and Prior Authorizations for COVID-19 Vaccines
Tufts Health Plan is not requiring referrals or prior authorizations for the administration of the COVID-19 vaccination, this includes the COVID-19 vaccine being administered by out-of-network (OON) providers during the PHE.
Provider Reimbursement for COVID-19 Vaccines
Tufts Health Plan is reimbursing for administration of the vaccines and services associated with vaccine administration for all products. The reimbursement rate includes vaccine administration, public health reporting, and patient outreach, education, and counseling.
While Tufts Health Plan encourages the use of in-network providers, we will reimburse in- and out-of-network providers for the administration of the vaccine.
Refer to the COVID-19 Vaccine and Testing Codes list for details for billing information.
- Tufts Health Public Plans, Massachusetts reimburses for the administration of COVID-19 vaccines and services associated with vaccine administration for all products at the designated State rate. When the vaccine is provided by the government at no charge to the provider no additional reimbursement will be paid. For more information, please refer to our COVID-19 page for providers and the COVID-19 Vaccine, Testing, and Treatment Code list, and 101 CMR 44.
COVID-19 Diagnostic Testing and Treatment
COVID-19 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.
- Tufts Health Plan covers in-person polymerase chain reaction (PCR), antigen and antibody laboratory testing for COVID-19 consistent with federal and state guidance at no cost to our members. These tests must be medically necessary, as determined by a health care provider, in accordance with current CDC and state public health department guidelines. Providers should not collect any cost share from members. Refer to the Medical Necessity Guidelines for COVID-19 Antibody (Serological) Testing for additional information on FDA-authorized antibody testing coverage.
- Tufts Health Plan is covering the cost of up to eight OTC at-home COVID-19 tests per member, per month for as outlined below. Coverage applies only for tests that are approved by or granted EUA by the FDA, are intended for individualized diagnosis or treatment of COVID-19 (not for resale) and are not for employment purposes.
- Commercial and Tufts Health Direct: Members should visit the Caremark website for the most up-to-date information on participating pharmacies to purchase the tests with no upfront costs. Commercial and Tufts Health Direct members paying for at-home tests out-of-pocket can also submit a member reimbursement form as outlined on the member COVID-19 Testing and Coverage page. We will only pay for eligible tests that are purchased on or after January 15, 2022.
- Tufts Health Together, Tufts Health RITogether, Tufts Health Unify and Tufts Health Plan SCO: Members can obtain coverage for five different brands of OTC tests through their pharmacy benefit. Members should visit an in-network pharmacy to purchase the tests with no upfront costs.
- Medicare Supplement: Over-the-counter COVID-19 tests are covered through Medicare. Members can visit a participating Medicare pharmacy location at no upfront cost. Please refer to medicare.gov for complete coverage information.
- Tufts Medicare Preferred HMO: As of April 4, 2022, anyone with Medicare Part B coverage, including those enrolled in a Medicare Advantage plan are covered under Medicare. Tufts Health Plan continues to offer coverage for at-home tests in addition to the Medicare coverage and is available through Dec. 31, 2022. Our member website includes detailed instructions for members on how to purchase these tests with no up front out-of-pocket cost at participating in-network pharmacies or how to submit for reimbursement.
- COVID-19 PCR tests that are laboratory processed and either conducted in person or at home must be ordered or referred by a provider to be covered benefits. Tufts Health Plan will not cover or reimburse for these tests for members when self-ordered, including when using an online self-completed questionnaire.
- Testing is not covered solely for general worlplace health and safety, public health surveillance, or for other purpose not primarily intended for a member's individual COVID-19 diagnosis or treatment. Diagnostic coronavirus testing required as a condition for travel inside or outside of the United States is not covered.
- Diagnostic testing required by a provider for surgical or other medical procedures is medically necessary and covered, including if pregnant or expectant parents are required to test prior to admittance to a delivery facility.
- Members are encouraged to see in-network providers, whenever possible. However, this policy applies to in-network and out-of-network (OON) providers. As always, coverage is only available to health plan members.
COVID-19 Treatment - Effective as outlined below
Members are encouraged to see in-network providers, whenever possible. However, these policies apply to in-network and out-of-network (OON) providers for all Tufts Health Plan products:
- Provider Reimbursement: Tufts Health Plan will reimburse providers for treatment according to covered benefits in our plans for those members positively diagnosed with COVID-19. 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 continues to waive member cost share, including copays, for COVID-19 treatment for Commercial and Tufts Health Direct members when COVID-19 is listed as a diagnosis on the claim. Refer to the COVID-19 Vaccine, Testing and Treatment Codes
list for additional information.
- Monoclonal Antibodies: Tufts Health Plan covers medically necessary monoclonal antibody treatment in outpatient settings, without prior authorization as per the Food and Drug Administration's (FDA) EUA criteria, 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. Please refer to the medical necessity guidelines for COVID-19 Monocloncal Antibody Therapy for additional information.
- Ivermectin: Dispensing of Ivermectin oral tablets is limited to 20 tablets within 90 days for Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether and SCO products. Ivermectin is not approved by the FDA for the prevention or treatment of COVID-19. Requests to exceed quantity limits will be approved for FDA-approved indications or those supported by compendia only. Requests to exceed quantity limitations for experimental or investigational use will be denied.
- Paxlovid and Molnupiravir: The FDA has authorized EUA for Pfizer's Paxlovid (nirmatrelvir/ritonavir) and Merck's Molnupiravir for the treatment of certain cases of COVID-19. When prescribed and dispensed under the requirements of the EUA, one course of therapy will have no cost share. Prescriber and pharmacy access is limited.
Temporary COVID-19 Telehealth Payment Policy
Refer to the Temporary COVID-19 Telehealth Payment Policy for the following:
Tufts Health Plan will continue to evaluate market conditions and will inform the network in advance of an end date or further changes to this temporary policy.
Referrals, Prior Authorizations and Notifications
In-Network Referral Policies – Effective as outlined below
Referral requirements continue to be waived, for all in-network care, regardless of diagnosis, for Senior Products, Tufts Health Together and Tufts Health Unify through the end of the federal COVID-19 PHE.
Out-of-Network Authorization Policies – Effective as outlined below
Tufts Health Plan continues to waive referral and authorization requirements to receive out-of-network (OON) services when related to a COVID-19 diagnosis for Massachusetts Commercial products, Tufts Health Direct, Tufts Health Together and Tufts Health Unify.
For all other states and products, refer to the medical necessity guidelines for Out-of-Network Coverage at the In-Network Level of Benefits (All Plans).
Prior Authorization Guidelines – Effective as outlined below
- Massachusetts Commercial and Tufts Health Direct: In accordance with Massachusetts Division of Insurance Bulletin 2022-03, and effective until May 16, 2022 (unless otherwise extended by state orders), prior authorization is being waived for scheduled surgeries, behavioral health (BH) and non-BH admissions at acute care, mental health hospitals and post-acute care facilities. This applies to COVID-19 and non-COVID-19 related services, including all inpatient treatment. Services that were prior approved but postponed due to COVID-19 will not require additional authorization if provided by June 15, 2022.
- Tufts Health Together, Tufts Health Unify and Tufts Health Plan SCO: In accordance with MassHealth Managed Care Entity (MCE) Bulletin 75, and effective until February 22, 2022 (unless otherwise extended by state orders), prior authorization is being waived for all scheduled surgeries, behavioral health and non-behavioral health admissions at acute care, mental health hospitals and post-acute care facilities. For Tufts Health Together and Tufts Health Unify, prior authorization for the treatment of COVID-19 will continue to be waived in accordance with Massachusetts Division of Insurance Bulletin 2021-08.
- Rhode Island Commercial and Tufts Health RITogether: Tufts Health Plan is relaxing prior authorization for hospital discharges to post-acute care facilities through February 28, 2022.
- All other products: Prior authorization requirements are in effect and pre-pandemic processes should be followed.
As a reminder, urgent/emergent admissions are never subject to prior authorization.
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.
For Massachusetts Commercial and Tufts Health Direct, in accordance with in Massachusetts Division of Insurance Bulletin 2022-03
, and effective until April 16, 2022 (unless otherwise extended by state orders), Tufts Health Plan is relaxing concurrent and retrospective reviews of the first five days of any post-acute facility stay following a transfer from an acute or mental health hospital.
For all other products, concurrent review requirements are reinstated for all inpatient treatment (including inpatient hospice services, behavioral health admissions at acute care hospitals or mental health hospitals), and pre-pandemic processes should be followed.
Tufts Health Plan remains available to assist with discharge planning for all admissions and reserves the right to retroactively review services for medical necessity.
Billing and Reimbursement Guidelines
Reimbursement for Inpatient Mental Health Services for COVID-19 Positive Members
Per MassHealth Managed Care Entity (MCE) Bulletin 83 , MassHealth requires Tufts Health Plan to temporarily increase rates for admitted COVID-19 positive Medicaid members effective Jan. 1 through May 1, 2022, or as otherwise directed by Massachusetts Executive Office of Health and Human Services (EOHHS). In order to administer this payment increase in accordance with the Bulletin, providers must complete the Behavioral Health Services Inpatient Notification Form when admitting a COVID-19 positive Tufts Health Plan MA Together MCO or ACO member, or when treating a Tufts Health Plan Together member that has become COVID-19 positive within 96 hours of admission. Refer to the form for submission instructions.
Billing by Certified Registered Nurse Anesthetists - Through the end of the Federal COVID-19 PHE
The following applies to all Tufts Health Plan products through the end of the federal COVID-19 PHE:
- Certified registered nurse anesthetists (CRNA) are not required to include the supervising physician information on claims. 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 as outlined below
CMS has extended the suspension of the sequestration payment reduction through March 31, 2022 and will phase it back in with a 1% sequester cut from April through June 2022. The 2% cut goes back into effect on July 1, 2022. As such, consistent with this CMS requirement, Tufts Health Plan 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.
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 lines of business.
Senior Products and Tufts Health Unify
The following Senior Products and Tufts Health Unify policies are in effect through the end of the Federal PHE:
- 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.
Credentialing of New Practitioners
COVID-19 Policies History
- April 22, 2022: Billing and reimbursement guidelines have been updated for reimbursement for inpatient mental health services for COVID-19 positive members
- April 15, 2022: Coverage of over-the-counter tests for Tufts Medicare Preferred HMO members has been revised
- March 8, 2022: Updated the prior authorization and concurrent review flexibilities for Massachusetts Commercial and Tufts Health Direct products per Massachusetts Division of Insurance Bulletin 2022-03.
- March 1, 2022: Updates made to the Provider Reimbursement for COVID-19 vaccines section
- February 16, 2022: Additional information was added for the coverage of at-home COVID-19 tests for Tufts Medicare Preferred HMO members.
- February 10, 2022: Updated coverage information for at-home tests for Tufts Health Medicare Preferred and Tufts Health RITogether members
- January 27, 2022: Clarified inpatient notification guidelines; updated coverage information for COVID-19 treatment; updated prior authorization information for Rhode Island members
- January 21, 2022: Updated COVID-19 testing coverage
- January 19, 2022: Updated coverage information for COVID-19 at-home tests
- January 11, 2022: Formatting updates; added vaccine coverage information from the retired COVID-19 Vaccination Payment Policy; updated COVID-19 testing section with information on at-home tests; updated the monoclocal antibodies billing information for Senior Products in the COVID-19 treatment section
- December 1, 2021: Prior authorization information for Tufts Health Together, Tufts Health Unify and Tufts Health Plan SCO in accordance with MassHealth Managed Care Entity Bulletin 75.
- November 24, 2021: Revised prior authorization and credentialing for Massachusetts Commercial and Tufts Health Direct in accordance with Massachusetts Department of Insurance Bulletin 2021-15.
- November 8, 2021: Waiving of COVID-19 treatment cost share for Rhode Island Commercial members through the end of the Rhode Island State of Emergency
- October 6, 2021: Waiving COVID-19 treatment cost share for Rhode Island Commercial members has been extended through October 30, 2021, due to the extension of the Rhode Island State of Emergency
- September 24, 2021: COVID-19 treatment and prior authorization guidelines updated for Massachusetts products in accordance with Massachusetts Division of Insurance Bulletin 2021-08, Ivermectin quantity limitation information and Medical Necessity Guidelines for COVID-19 Antibody (Serological) Testing
- September 9, 2021: Continuing to waive COVID-19 treatment cost share for Rhode Island Commercial members through October 2, 2021 due to the extension of the Rhode Island State of Emergency
- August 27, 2021: Clarified coverage of monoclonal antibody treatment; removed previously end dated credentialing and pharmacy policies
- August 10, 2021: Waiving cost share for COVID-19 treatment has been extended through September 5, 2021 for Rhode Island Commercial Products due to the extension of the Rhode Island State of Emergency
- July 30, 2021: Reinstating member cost share for Massachusetts Commercial and Tufts Health Direct members when diagnosis code Z03.818 is billed, effective for dates of service on or after September 30, 2021; removed Behavioral Health policies with July 15, 2021 end date
- July 26, 2021: Removed billing information for diagnosis code B97.29, information for Bulletin 2020-23, DME, medical supplies and home health services; added end dates for CRNA and Senior Products and Tufts Health Unify pharmacy policies, clarified prior authorization policies
- July 9, 2021: Revised prior authorization information; waiving medical prior authorization through September 30, 2021 and Behavioral Health prior authorizations through December 31, 2021 for Tufts Health RITogether and reinstating prior authorization for non-hospital locations for post-acute care for dates of service on or after August 7, 2021 for Tufts Health Together
- June 17, 2021: Reinstating cost share for COVID-19 treatment for Tufts Health Freedom Plan members, effective for dates of service on or after August 7, 2021; Referrals continue to be waived for in-network services Tufts Health Together for the duration of the federal PHE
- 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 PHE. 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.