When You Have Questions or Concerns About Your Coverage
As a Tufts Health Plan member, your input is important to us
There’s a way you can ask questions or tell us your concerns about health care services or the coverage you get from Tufts Health Plan. There’s also a way for you to ask for a review of a decision we have made about covering a health care service. Depending on the type of plan you are on, here is a guide letting you know where you can get answers to questions about your plan. If you don’t know what kind of plan you are on, ask your employer or call a member service representative at the number on your member ID card.
If you are covered under a Massachusetts fully insured plan
- You may be able to have certain decisions we have made reviewed by an external review agency designated by the Massachusetts Health Policy Commission (HPC) Office of Patient Protection (OPP)
If you are covered under a Rhode Island fully insured plan
- You may be able to have certain decisions we have made reviewed by an external review agency designated by the Rhode Island Office of the Health Insurance Commissioner (RI OHIC).
If you are covered under a self-funded plan
- Your self-funded plan may provide for an independent review of certain decisions by an external review agency.
About the review agencies
The external review agencies designated by the Massachusetts OPP, the Rhode Island DOH, or your self-funded plan are independent organizations that check decisions your plan makes about covering health care services. The external review agencies are not connected in any way to Tufts Health Plan or your self-funded plan.
To learn more about a review
For more information about how to ask for a review of a decision we’ve made about covering a health care service:
- Check your member benefit document.
- Call a member service representative at the number on your member ID card.
- Read more about how to do it in your Member Handbook. You can find it in the Member Forms + Documents section, select your plan, and click on “Handbooks”. Or ask a member service representative to send you a copy.