Frequently Asked Questions (FAQs)

Tufts Health Unify


Overview


What is the One Care program?

The One Care program is a collaborative initiative between MassHealth and the Centers for Medicare & Medicaid Services (CMS) to integrate care for people who are eligible for both Medicare and Medicaid.

What is Tufts Health Unify?

Tufts Health Unify is our Medicare-Medicaid One Care plan for people ages 21 – 64. Tufts Health Plan launched Tufts Health Unify to provide enrollees who live in Worcester, Suffolk or Middlesex counties with access to One Care's comprehensive care delivery system.

Can individuals who are eligible for both Medicare and Medicaid decide to keep their existing Medicaid or Medicare coverage and not join the One Care program?

Yes. Individuals may opt out of One Care, but they must notify MassHealth of their decision not to participate in the program.


General


Can enrollees select a primary care provider (PCP) or specialist outside of Worcester, Suffolk or Middlesex counties?

Yes. Tufts Health Unify enrollees who live in Worcester, Suffolk or Middlesex counties may seek care from a contracted Tufts Health Plan PCP or specialist in another county. Please use our Find a Doctor or Hospital search to determine which providers are in-network for Tufts Health Unify.

Should I collect co-payments from my Tufts Health Unify patients?

No. There are no co-payments for Tufts Health Unify enrollees.

Must all facilities contracted for Tufts Health Unify comply with the Americans with Disabilities Act (ADA)?

Yes. MassHealth and the Centers for Medicare & Medicaid Services (CMS) require ADA training and compliance. You can contact our ADA compliance manager at ADACompliance@tufts-health.com with questions or to request a list of ADA resources. You can also find more information about ADA training at the state's One Care learning website.

Can the care plan/centralized enrollee record (CP/CER) tool interface with my electronic medical record (EMR)?

No. We will let you know if this interface is available in the future.


Training


How can I learn more about One Care?

You can learn more about One Care from any of the following resources:

What are the training requirements for providers?

The Executive Office of Health and Human Services (EOHHS) and the Centers for Medicare & Medicaid Services (CMS) require providers and office staff to complete comprehensive training on the program. This training program has two tracks:

Track one

  • A training series developed by UMass Medical School and MassHealth to provide foundational information on the One Care program, which is designed to improve health care quality through person-centered, coordinated care.
  • To learn more about this training series, please visit the One Care learning website.

Track two

  • Our Tufts Health Unify plan-specific training fulfills your Tufts Health Plan training requirement. The training document explains your day-to-day interactions with us and includes topics regarding our model of care and administrative processes.
  • Once you have read the document, you must submit the requested information at the bottom of the training page to receive credit and fulfill your training requirement.

You must complete both training program tracks to meet One Care requirements, and we will record and submit your participation in the Tufts Health Unify training to both EOHHS and CMS.

Am I required to take the Tufts Health Unify training?

Yes. All contracted providers and staff, including providers outside of Worcester, Suffolk and Middlesex counties, must fulfill the Tufts Health Unify training requirement.

Why am I required to take the Tufts Health Unify training if I practice outside of Worcester, Suffolk and Middlesex counties?

Although we only cover enrollees who live in Worcester, Suffolk and Middlesex counties at this time, enrollees may seek health care services from contracted providers in other counties.

How do I fulfill my Tufts Health Unify training requirement?
If you have not already completed the Tufts Health Unify provider training, you can access our training document. Please note: To fulfill your training requirement, you must submit the requested information at the bottom of the training page.
Will Tufts Health Plan require additional training if Tufts Health Unify expands to more counties?

At this time, you only need to read our training document regardless of the county in which you practice. Tufts Health Plan may require additional training in the future and will inform you of the required training by including notification in the Provider Update newsletter and or additional content on the training page.

 


Contracting and Credentialing


If I am already credentialed with Tufts Health Plan, do I need to re-credential for Tufts Health Unify?

No. If you are currently a Tufts Health Plan provider, you will not need to re-credential for Tufts Health Unify.

If my practice currently accepts Tufts Health Plan, do we need to sign a new contract forTufts Health Unify?

Yes. If you have not done so already, you will need to sign a separate contract amendment before you can start seeing Tufts Health Unify enrollees. If you would like to become a contracted provider for Tufts Health Unify, get started by joining our network.

How do I know if I'm contracted for Tufts Health Unify?

You need to sign a contract amendment. If you are not sure if your practice has contracted for Tufts Health Unify, please contact Provider Services at 888.257.1985.

What should I do if I'm not contracted for Tufts Health Unify and an enrollee shows up in my office?

Before delivering care, please always check member eligibility and let your patient know that you are an out-of-networkprovider.

We only cover care rendered by in-network providers, with the following exceptions:

  • Emergency, urgent, or post-stabilization care
  • Family-planning services from a MassHealth-contracted family-planning services provider
  • Services uniquely available from an out-of-network provider, with prior authorization
  • Kidney dialysis services rendered by a Medicare-certified dialysis facility, if the enrollee is outside the plan's service area for a short time

When enrollees first join Tufts Health Unify, they may continue seeing their current providers for 90 days or until an alternative care plan has been agreed upon. There are exceptions in which enrollees may continue to see their provider, such as if:

  • The enrollee is currently in treatment for, or managing, chronic issues (like dialysis, home health, chemotherapy, and/or radiation), including previously authorized services or covered services; they may be able to keep seeing their provider beyond 90 calendar days with prior authorization
  • The enrollee is in her second or third trimester of pregnancy; she may be able to keep seeing the provider up through delivery and her first follow-up checkup
  • The enrollee is terminally ill; they may be able to keep seeing their provider while they are sick
Who can be a contracted provider for Tufts Health Unify?

If you provide a service covered by Tufts Health Unify, you can get started by joining our network. For more information on covered services, please see our medical and behavioral health benefit summary grids.

Examples of providers who may contract with Tufts Health Unify include, but are not limited to:

  • Primary care providers (PCPs) and specialists
  • Long-term supports (LTS) coordinators at community-based organizations
  • Licensed mental health counselors and licensed social workers
  • Masters-level behavioral health care providers
What is my fee schedule for Tufts Health Unify?

We will reimburse you for services rendered to Tufts Health Unify enrollees at the rate specified in yourTufts Health Unify provider contract.

Does the contract contain a "no cause" termination clause?

No. The contract does not contain a "no cause" termination clause.

Where can I get a list of contracted Tufts Health Unify providers?

You can find a list of contracted providers using the Find a Doctor or Hospital search.


Delivering Care

 

Care Coordination


Can enrollees choose the providers on their interdisciplinary care team (ICT)?

Yes. Enrollees are the center of the ICT and may choose their providers, designating any provider or individual as part of the ICT.

How do you handle existing patients in the transition between enrollment and assessment?

We reach out to enrollees once they enroll with Tufts Health Unify, but we do not provide care coordination until their coverage effective date. When we outreach, we will review any available claims data and schedule face-to-face assessments to prepare for transition-of-care issues.

Will your business processes change if care coordination or clinical management is done at the primary care provider (PCP) site?

No. Our business processes will not change if care coordination or clinical care management takes place at the PCP site. We will assess any site interested to ensure they have the necessary resources to coordinate care and partner with the site to provide the necessary support.

In complex cases, how does the Tufts Health Unify care team work with other disability services, such as the Department of Mental Health (DMH)?

The Tufts Health Unify care team alerts the DMH when members enroll with Tufts Health Plan. We then assign a case worker to the enrollee's interdisciplinary care team (ICT).

If an enrollee needs personal care attendant (PCA) services, will a long-term supports (LTS) coordinator be involved?

Yes. An LTS coordinator helps coordinate an enrollee's care with the PCA.

How will you coordinate transportation services?

The Tufts Health Unify care team processes requests for emergency and nonemergency transportation. We then submit an assessment of the requested transportation and issue an authorization, if appropriate.

Who calls durable medical equipment (DME) providers for equipment servicing?

Enrollees can call the DME providers directly with any issues with their product or they can have their dedicated clinical care manager call on their behalf.


Doing Business With Us

Eligibility


What are the eligibility requirements for enrollees in the One Care program?

All One Care enrollees must meet the following eligibility requirements:

  • Eligibility for Medicare Parts A and B
  • Eligibility for MassHealth Standard or CommonHealth
  • No other comprehensive private or public health plan coverage
How do I check an enrollee's eligibility for Tufts Health Unify?

There are several ways you can check an enrollee's eligibility:

All enrollees will also have a Tufts Health Unify member ID card.

How can I check the enrollees assigned to my panel?

Primary care providers (PCPs) can check the enrollees in their panel through Tufts Health Plan's secure Provider portal. Remember, the enrollee must be in your panel on the date of service. Refer to the Tufts Health Public Plans Provider Manual for additional information. 
 

Is an enrollee's coverage effective as soon as they enroll?

An enrollee's coverage is usually effective on the first day of the month following his or her enrollment. For example, if the enrollee joined during open enrollment on September 1, 2019, his or her coverage began on October 1, 2019.

Do you cover enrollees older than 64 under One Care?

If eligible individuals enroll when they are 64 or younger, they may remain in the One Care program as long as they remain eligible for both Medicare and Medicaid, and Tufts Health Plan waives the age requirement.

Will government programs such as HIV Drug Assistance Program (HDAP) impact eligibility for enrollees living with chronic conditions such as HIV/AIDS?

No. HDAP is for low-income individuals with HIV (500% of the Federal Poverty Level), usually recently unemployed or without other insurance. One Care covers anti-retrovirals, making HDAP unnecessary for One Care enrollees.


Benefits


What services does Tufts Health Unify cover?

The One Care program combines the benefits of Medicare and Medicaid to create a more robust list of covered services, including a variety of long-term services and supports. For more details, see our medical and behavioral health benefit summary grids. If the benefit summary grids do not answer your question, please call Provider Services at 888.257.1985.

Will Tufts Health Unify coverage match Medicare's coverage guidelines?

It depends on the service. Please check our medical and behavioral health benefit summary grids for the specific service.

Can I render services to an enrollee if Tufts Health Plan hasn't yet completed the comprehensive assessment?

Yes. You may render services before the assessment is completed.

Will third-party liability go away?

No. Third-party liability rules still apply to Tufts Health Unify.


Prior Authorizations and Referrals


How do I know if a service requires a referral or prior authorization?

We require a primary care provider (PCP) referral for specialty services for members in certain provider systems. You can check which members require a referral, or the status of an existing referral request through Tufts Health Plan's secure Provider portal or by calling us at 888.257.1985. You can also look for "PCP referral required" on the member's ID card.

We require prior authorization for some services. For more information, see our medical and behavioral health benefit summary grids and payment policies.

Who requests referrals and prior authorizations?

Providers are responsible for obtaining referrals, when necessary.

The enrollee, their primary care provider (PCP), specialist, or any member of the interdisciplinary care team may request prior authorization.

Is the prior authorization process the same for Tufts Health Unify and Tufts Health Plan's other plans?

The prior authorization process is almost the same. The only difference is that either the Tufts Health Unify enrollee or his or her provider may request prior authorization. To request prior authroization, please refer to the Utilization Management chapter of the Tufts Health Public Plans Provider Manual. For additional information, contact Provider Services at 888.257.1985.

 


 
Is the referral process the same for Tufts Health Unify and for Tufts Health Plan's other plans?

Yes. The referral process is the same for Tufts Health Unify as it is for our other plans.

Do you allow outpatient behavioral health (BH) visits without prior authorization?

Yes. We allow 12 outpatient BH visits per benefit year without prior authorization for some Current Procedural Terminology (CPT) codes (90791, 90832, 90834, 90846, 90847, 90849). When submitting your claim, please select the appropriate CPT code that indicates the length of the session.

These 12 visits are separate from psychiatric medication visits, psychotherapy for crisis, groups, and collateral contacts, which are exempt from prior authorization. If your patient needs more than 12 outpatient BH visits, please request prior authorization one to three weeks prior to the last covered visit.

Is the process to request additional behavioral health (BH) visits the same for Tufts Health Unify andTufts Health Plan's other plans?

Yes. The prior authorization process for BH services is the same for Tufts Health Unify and our other plans.

Do you authorize a standard number of visits? If so, will you authorize additional visits for patients with certain conditions?

We approve the initial evaluation and review the assessment to determine the number of visits, following MassHealth and CMS guidelines.

Do you extend the five-day authorization window for durable medical equipment (DME) for Tufts Health Unifyenrollees?

Yes. We will extend the five-day authorization window for DME.

If the enrollee is renting durable medical equipment (DME) and wants to switch plans, will the provider need to submit an authorization request to the new insurer?

Yes. We cover existing DME rentals under our continuity of care guidelines, but you must request prior authorization.

If I am out-of-network, can I see Tufts Health Unify enrollees?

Yes, but you will need prior authorization before rendering care to a Tufts Health Unify enrollee.


Billing and Reimbursement


Should I submit claims to you, or must I also bill Medicare and Medicaid?

The One Care program consolidates billing to make it easier for you to get paid. Please submit all claims toTufts Health Plan for services rendered to Tufts Health Unify enrollees.

How do I submit claims? Is the process the same as for the other Tufts Health Plan plans?

Yes. Our claims process is the same for all our plans.

Please see the Claims Requirements and Dispute Guidelines chapter of the Tufts Health Public Plans Provider Manual for information about submitting claims electronically. A member of our e-business team can also work with you individually to help determine the electronic claim submission method that's right for you. Call Provider Services at 888.257.1985.

Please send all paper claims to us at:

Tufts Health Plan
P.O. Box 8115
Park Ridge, IL 60068-8115

Do you reimburse for two services if delivered on the same date of service?

It depends on the service. Please see our payment policies for more detail about the specific service.

Can I bill for services not normally covered by Medicare?

It depends on the service, as some services are covered by Medicaid. Please see our medical and behavioral health benefit summary grids for coverage information for the specific service.

Where can I find administrative guidelines for the services I offer?

Please see a comprehensive list of our payment policies. You can also call Provider Services at 888.257.1985 if you have additional questions.

Since day services rates are not set by MassHealth, will you use Department of Developmental Services (DDS) reimbursement rates set by Chapter 257?

We do not reimburse for day services for developmental disability providers. DDS will continue to pay for these services.

How should home infusion providers bill for medications for Tufts Health Unify enrollees?

Pharmacy providers are responsible for filing pharmacy claims for Tufts Health Unify enrollees. If you need home infusion medication for a Tufts Health Unify enrollee, please send a prescription to the pharmacy. The pharmacy will then deliver the medication to the enrollee and bill Tufts Health Plan.


Provider Network



Will Tufts Health Plan expand beyond Middlesex, Suffolk and Worcester counties?

At present our service area includes Middlesex, Suffolk and Worcester counties. We currently have a strong provider network in all three counties and beyond to help us provide access to high-quality care for Tufts Health Unify enrollees. We hope that there will be an appropriate opportunity to expand into other areas in the future.

I am a contracted provider outside of Middelsex, Suffolk and Worcester counties. Can I still see Tufts Health Unify patients?

Yes. As a contracted provider for Tufts Health Unify, you are still considered in-network and may seeTufts Health Unify enrollees even if you are not located within Middlesex, Suffolk or Worcester counties.

I am a contracted provider located within Middlesex, Suffolk and Worcester counties. Can I refer patients to a contracted provider outside of these service areas?

Yes. All providers who are contracted for Tufts Health Unify are considered in-network, even if they are located outside of Middlesex, Suffolk and Worcester counties.

Can enrollees continue receiving treatment from an out-of-network provider, or will they have to select an in-network provider?

When enrollees first join Tufts Health Unify, they may continue seeing their current providers for 90 days or until an alternative care plan has been agreed upon. There are exceptions in which the enrollee may continue to see their provider beyond 90 days, such as if:

  • The enrollee is currently in treatment for, or managing, chronic issues (like dialysis, home health, chemotherapy, and/or radiation), including previously authorized services or covered services; they may be able to keep seeing their provider beyond 90 calendar days with prior authorization
  • The enrollee is in her second or third trimester of pregnancy; she may be able to keep seeing the provider up through delivery and her first follow-up checkup
  • The enrollee is terminally ill; they may be able to keep seeing their provider while they are sick
Who should I contact if I have questions?

We have a number of resources available to help answer your questions:

If you still have questions, please contact Provider Services at 888.257.1985.

 

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