Provider Credentialing

Commercial

MDs, DOs, DPMs and Oral Surgeons

If you are an MD, DO, DPM or oral surgeon and participate in an IPA or PHO, and you are interested in contracting with Tufts Health Plan, contact the Provider Unit or IPA/PHP Administration of the hospital with which you are affiliated to obtain a contract for your review and signature. Once signed, complete a HealthCare Administrative Solutions (HCAS) Provider Enrollment Form. Submit the contract and enrollment form to Tufts_Health_Plan_Credentialing_Department@tufts-health.com.

Complete the credentialing application on the CAQH website.

If you are an MD, DO, DPM or oral surgeon and you are not participating in an IPA or PHO, but would like to join Tufts Health Plan Commercial products, email Tufts_Health_Plan_Credentialing_Department@tufts-health.com. We will email you a contract for signature. Complete the contract and the HCAS Provider Enrollment Form and submit both to Tufts_Health_Plan_Credentialing_Department@tufts-health.com.

Complete the credentialing application on the CAQH website.

For other resources and important information, visit the HCAS website.

Allied Practitioners

Allied practitioners should refer to the Allied Health Providers page for more information on specific credentialing requirements.

More Information

In most cases,Tufts Health Plan approves clean and complete (no adverse responses) applications within 30 days of receipt of a clean, complete application. To check the status of your application, email Tufts_Health_Plan_Credentialing_Department@tufts-health.com. We re-credential all of our providers at least every two years to meet regulatory and accreditation guidelines.

If you have questions regarding credentialing, email Tufts_Health_Plan_Credentialing_Department@tufts-health.com.

Practitioner Rights

Practitioners have the right, upon written request, to:

  • Review Tufts Health Plan’s credentialing policies and procedures
  • Be informed of the status of their credentialing or recredentialing application
  • Review information submitted to Tufts Health Plan for purposes of credentialing or recredentialing the practitioner, including information obtained by Tufts Health Plan from any outside primary source, such as a malpractice carrier, state license board, or the National Practitioner Databank (NPDB). Tufts Health Plan is not required to reveal the source of information if the information was not obtained for the purpose of meeting Tufts Health Plan’s credentialing requirements.  Practitioners are not entitled to review references, recommendations, information that is peer-review privileged or information which by law Tufts Health Plan is prohibited from disclosing.
  • Be notified by Tufts Health Plan in the event that credentialing information that it has obtained from sources other than the practitioner varies substantially from credentialing information provided to Tufts Health Plan by the practitioner. Tufts Health Plan is not required to reveal the source or contents of the information if the information is not obtained for the purpose of meeting Tufts Health Plan’s credentialing requirements.
  • How to correct erroneous information submitted by another party: If we obtain or receive information during the credentialing process that varies substantially from the information you provided in your application, we will notify you of the discrepancy. You have the right to review any information submitted in support of your credentialing application and to correct erroneous information other parties give us (excluding peer-review information). Please submit your corrections to the Credentialing Department within 10 days of receipt by emailing Tufts_Health_Plan_Credentialing_Department@tufts-health.com.
  • There is no right of appeal from an initial credentialing determination by the Quality of Care Committee (QOCC), except when required by applicable state or federal law.
  • In the event the QOCC votes to take disciplinary action, the practitioner is entitled to notice consisting of a written statement of the reasons for the action and, if applicable, has the right to appeal such action by filing a written appeal within thirty (30) calendar days of receipt of the statement of reasons.

Additional rights for Rhode Island practitioners

  • The practitioner will receive a response from Tufts Health Plan regarding his/her application within 180 calendar days after receipt of the application.
  • If a credentialing decision is made to deny credentials to a practitioner, the QOCC will send the practitioner written notification of all reasons for the denial within sixty (60) calendar days of receipt of the completed and verified application.
  • If the QOCC votes to take disciplinary action against a practitioner, the practitioner shall have thirty (30) calendar days from the receipt of the letter from the QOCC to notify Tufts Health Plan in writing that he/she will appeal the QOCC decision. If the practitioner exercises his/her appeal right, Chair of the QOCC will arrange for a hearing before an Appeals Committee that shall review the decision of the QOCC and issue a decision prior to implementation of the disciplinary action against the practitioner. The process outlined in the Tufts Health Plan appeals process will be followed.
  • If requested in writing by a practitioner whose credentials have been revoked or adversely modified, the due process outlined in the Tufts Health Plan appeals process shall be waived.