Advantage HMO Plan FAQs

For full information about your Tufts Health Plan coverage, please review your member benefit document. If there is a difference between the information here and your member benefit document, please rely on your member benefit document.

  • Do I have to choose a primary care physician (PCP)?
  • How can I find a PCP who participates in my specific Tufts Health Plan network?
  • What should I do if my PCP is listed in the online Provider Directory, but is shown as "accepting current patients only"? Can I still choose him or her as my PCP?
  • What if my PCP is not in your directory of providers?
  • How can I notify Tufts Health Plan that I have changed my PCP?
  • Can my current PCP join your network, if he/she does not participate at this time?
  • Will I need a referral to see a specialist?
  • Who is responsible for obtaining any needed authorizations and preregistrations?
  • Am I covered for emergency care?
  • What is utilization management?
  • What member discounts are available for fitness services?
  • How can I obtain more information about my Tufts Health Plan coverage?

Do I have to choose a primary care physician (PCP)?
Members of our health maintenance organization (HMO) plans must choose a PCP who participates in their specific Tufts Health Plan network - Standard or Select - to be covered for services under their plan. Your network PCP will provide or authorize your care.

How can I find a PCP who participates in my specific Tufts Health Plan network?
To find a PCP or other provider who participates in your specific Tufts Health Plan network (Standard or Select), use our Doctor Search. To determine if you are an HMO Select member, check your member ID card, which will include the term "Select" in your plan name.

What should I do if my PCP is listed in the online Provider Directory, but is shown as "accepting current patients only"? Can I still choose him or her as my PCP? 
If you are a current patient of the PCP, you may continue to see that doctor for your care. If you are not a current patient of a PCP who is listed as not accepting new patients, you must choose another PCP who participates in your specific Tufts Health Plan network.

What if my PCP is not in your directory of providers? 
If your PCP does not appear in our directory of providers - which you can access through theDoctor Search function here on our website - it means your doctor does not participate in Tufts Health Plan's provider networks. As an HMO member, you must choose a PCP who participates in your specific Tufts Health Plan network - Standard or Select.

How can I notify Tufts Health Plan that I have changed my PCP?
Just go to your personal benefit account in our secure online Member Resource Center here on our website and make the change. To access your personal account, you will first have toregister on our website and then use the temporary password we will mail you to activate your personal benefit account. If you are unable to change or add your PCP in your personal account, please call the Member Services Department at the number listed on your Tufts Health Plan member ID card.

Can my current PCP join your network, if he/she does not participate at this time?
If your current doctor is interested in becoming a Tufts Health Plan-participating provider, he or she can call our Provider Credentialing Department to obtain more information.

Will I need a referral to see a specialist?
If you are an HMO member seeking specialty care, your network PCP will assess your medical needs, and, if necessary, will refer you to a specialist who participates in your specific Tufts Health Plan network.

Who is responsible for obtaining any needed authorizations and preregistrations?
Your Tufts Health Plan-participating PCP or other network providers are usually responsible for obtaining needed coverage authorizations for you as an HMO member. You can check any necessary authorizations or preregistrations you may need before upcoming appointments or procedures by going to your personal benefit account in our secure, online Member Resource Center.

Am I covered for emergency care?
If you have an emergency medical condition, Tufts Health Plan covers treatment and ambulance service. A PCP referral is not required before receiving emergency care. If you receive care in an emergency, you or someone acting on your behalf should notify your PCP within 48 hours. In an emergency, remember to seek care at the nearest medical facility. Call 911 for emergency medical assistance, if needed. If 911 services are unavailable in the area, call local emergency medical services or the police.

What is utilization management?
Tufts Health Plan has a utilization management (UM) program, or as it is sometimes called, utilization review program. The purpose of the UM program is to control health care costs by evaluating whether health care services provided to members are medically necessary and provided in the most appropriate and efficient manner.

Medical necessity criteria used for determining coverage are developed with input from practicing physicians in Tufts Health Plan networks; produced in accordance with regulatory requirements and standards adopted by national accreditation organizations; reviewed yearly and updated as new treatments, applications, and technologies are adopted as generally accepted medical practice; and evidence-based, as practicable.

What member discounts are available for fitness services?
Tufts Health Plan offers members a fitness program with great value. All members can take advantage of our valuable discounts and wide network of participating fitness centers and gyms, including:

  • Fitness centers in the Tufts Health Plan network
  • Curves
  • Fitness Together personal training
  • Appalachian Mountain Club
  • Boys & Girls Clubs

Find a fitness center in the Tufts Health Plan network.

How can I obtain more information about my Tufts Health Plan coverage?

  • Read your member benefit document.
  • Access your personal benefit information in your online account in our secure Member Resource Center. Register on our website and activate your account with the temporary password we will send you.
  • Contact a member specialist in our Member Services Department.
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