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Additional Resources and Frequently Asked Questions


About My Care and Coverage

My Care

Do you have my doctor?

Chances are good that your doctor is in our network, which has more than 51,000 health care professionals and 100 hospitals across New England. Our network stretches across all of Massachusetts, Rhode Island and New Hampshire, and extends into parts of Maine, Vermont, New York and Connecticut.

Take a look at our provider search to see if your doctor is in our network.

What if I am under the care of a specialist?

If your plan requires a referral from your PCP for specialist care, you’ll need to get a Tufts Health Plan referral. Any referral you had with your old insurance plan will not carry over.

Also, if you see any other providers for care, be sure to let them know that you have new health insurance. If one of your current providers is not in our network, you may need to switch to one who is.

What if I am scheduled for surgery?

Contact member services at the phone number on your ID card as soon as possible. We can coordinate any necessary evaluation or prior authorization in a timely manner.

What if I am pregnant?

Please call Member Services at 800-462-0224. Let us know your expected delivery date and the name of your doctor. This will allow us to pre-register you for your hospital admission.

 

My Medications

Is my medication covered? What do I do if it isn't?

If your plan includes a pharmacy benefit, you can find out by searching the name of your medication on our list of covered drugs (also referred to as a formulary). You can find your plan’s formulary in the My Coverage section of mytuftshealthplan.com by selecting Pharmacy.

If you’re prescribed a brand-name drug that has a safe, effective alternative or a generic version, we'll cover that instead. In some cases, your doctor may believe you should be treated because of a medical reason with a drug that is not covered. If so, he or she may submit a request for coverage, and we will review it closely for consideration.

If you have any questions about your drug coverage, you can always call the Member Services number on your ID card.

 

Referrals

What is a referral and when do I need one?

A referral is written permission from your Primary Care Provider to see a specialist for care. Certain plans, such as HMO and POS plans, require you to get a referral. Other plans, including PPO plans, do not require a referral. If you’re uncertain about whether or not you need a referral, call the Member Services number on your ID card.

If your plan requires a referral, your PCP will write a referral for you. Always make sure your PCP has made the referral before you see the specialist or you may be responsible for costs from the appointment.

How long is a referral valid?

A referral is valid for the number of visits approved by your Primary Care Provider. If you don’t use all the visits, the referral expires one year from the date it was written. Also, if you change your PCP, you will need to get a new referral from your new PCP regardless of whether you have visits left on a referral written by your former PCP.

 

Prior Authorizations

What is prior authorization?

Prior authorization means that we must approve a certain procedure or service before you receive it. Your doctor submits a request to us and we review it for medical necessity. We check to make sure you receive the appropriate level of care, at the appropriate time, in the right setting, and in the most efficient manner.

We use your plan’s Medical Necessity Guidelines and work with your doctor(s) to determine prior authorization. The guidelines are based on the latest medical evidence, leading scientific information, and expert opinion. We review our guidelines annually and as new information becomes available.

How do I get prior authorization?

Your in-network doctor is responsible for obtaining prior authorization from us on your behalf. If you go to an out-of-network doctor, then you are responsible for making sure the doctor obtains prior authorization.

Why do I need prior authorization if I already have a referral?

They are two different things. Your PCP issues a referral, which is his or her written permission for you to see a specialist. Your treating practitioner requests a prior authorization, which is permission from Tufts Health Plan for a specific service.

 

Care When I Travel Out-of-Network

How can I get access to a doctor when traveling?

If you have a life-threatening emergency medical condition, seek care immediately at the nearest medical facility. Tufts Health Plan covers any emergency medical care you may need, whether or not you receive the care from a provider in our network.

If you’re traveling outside Massachusetts, Rhode Island or New Hampshire, you have access to the Cigna PPO Network for both emergency and urgent care.


About My Documents

Summary of Benefits + Coverage

You have the right to an easy-to-understand summary about a health plan’s benefits and coverage, commonly known as an SBC. This information helps you make “apples-to-apples” comparisons when you’re looking at plans. 

The SBC shows how you and the plan share the cost for covered health care services, and also includes details - or “coverage examples” - which show you what the plan would cover in 2 common medical situations: diabetes care and childbirth. A glossary of terms used in health coverage and medical care is also included.

Keep in mind the SBC is only a summary. For detailed information about your plan’s coverage, log in to the secure portal to view your Benefit Document.

Benefit Document / Evidence of Coverage / Certificate of Insurance

Your Benefit Document (sometimes referred to as an Evidence of Coverage (EOC) or Certificate of Insurance (COI)) is a legally binding document provided by us that gives you a complete overview of your covered medical services. 

The Benefit Document explains your medical coverage, including covered benefits, exclusions, termination, continuation of coverage, and appeals. If there is a difference between the information in this Welcome Kit and your Benefit Document, please rely on your Benefit Document. 

You can find your Benefit Document on mytuftshealthplan.com. In the My Coverage (1) section, select My Benefits and look for the link under your plan name (2).

Explanation of Benefits

What is an Explanation of Benefits (EOB)?
An EOB, or explanation of benefits, is not a bill. It's a report that provides you with useful information about how we processed claims from providers who rendered care for you. The EOB shows what charges were submitted to us, and what amount you owe to the provider, if any.

How to read your EOB

How to Find an EOB
Not all processed claims trigger an EOB. You receive an EOB only when we have processed claims that affect your plan's limits, such as deductibles, coinsurance, and out-of-pocket maximums. And because EOBs indicate any financial responsibility you may have for health care services you have received, EOBs help you check the accuracy of bills from your providers.

You can find the EOB for a claim, if one has been generated, on mytuftshealthplan.com. In the Claims section, find the claim in the summary list and select Details to view the Claims Details page (1).


About My Costs

Why did I receive a bill from the provider?

You may have received a bill from the provider because you are responsible for paying a cost-share amount for the care you received, such as a deductible, copayment, or coinsurance.

Before you pay a provider’s bill, we encourage you to compare it to your claims summary on mytuftshealthplan.com to confirm how much you owe. Simply select Claims in the menu after you’ve logged in.

The claims summary shows details for each of your claims, including:

  • the date of service
  • the provider and provider specialty
  • the amount billed
  • the amount you may be responsible for*

Select the Details link next to a claim to view the claim status and a breakdown of services and payment details for that claim.


If the amount you owe on the provider’s bill differs from that of your claims summary, call member services at the phone number on your ID card. A representative can help determine the correct amount, if any, that you should pay—and can contact the provider if necessary.

*Note: If you received any non-covered services, you may also be responsible for the cost of those.

What are claim details?

Claim details show the specific information we used to process your claim. They include:

  • the date of service
  • a description of the service
  • the amount billed
  • the amount Tufts Health Plan paid, and
  • your cost-share responsibility, if there is one

In the Claims section of mytuftshealthplan.com, select the Details link next to a claim in the claims summary to view the claim details.