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, a 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 that 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 provider_data_request@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.

Additional rights for Rhode Island practitioners

  • The practitioner will receive a response from Tufts Health Plan regarding his or 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 or she will appeal the QOCC decision. If the practitioner exercises his or her appeal right, the 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.

For questions, please email provider_data_request@tufts-health.com.