With electronic data interchange (EDI), providers can submit claims electronically (either directly or through a clearinghouse) and receive electronic remittance from Tufts Health Plan.
For quicker payment, fewer rejections and ease of processing, providers can send their claims electronically to Tufts Health Plan using the following options:
Direct EDI Claim Submission
For direct submission, a provider's billing system is set up to connect with the claims system at Tufts Health Plan. Direct claim submission also includes support with a Tufts Health Plan EDI analyst for quick resolution of any EDI issues. There are no charges for direct claims submission.
For more information about direct EDI claim submission, call 888.880.8699, ext. 54042 or email questions to firstname.lastname@example.org.
Note: Claims submitted without a registered provider’s NPI, dental, and pharmacy claims cannot currently be submitted via EDI.
Clearinghouse Claim Submission
Tufts Health Plan accepts EDI claims from all major clearinghouses. Send one electronic file for all your claims to the clearinghouse. The clearinghouse, in turn, distributes those claims to all of the payers, including Tufts Health Plan. There is usually a fee associated with using a clearinghouse. Click here to access the EDI set-up form.
Before beginning, contact the Tufts Health Plan EDI Operations Department at 888.880.8699, ext. 54042.
Online Claim Submission
Tufts Health Plan now offers online claim submission to its providers through MD On-Line, now part of the ABILITY® Network. This option is available for professional claims only for all Tufts Health Plan products.
Providers who are already registered with MD On-Line may add Tufts Health Plan as a payer. Providers who are not yet registered should call MD On-Line at 888.499.5465 and mention that you are a Tufts Health Plan provider. All questions about registration should be directed to MD On-Line.
Note: Claims that require supporting documentation cannot be submitted electronically and providers should continue to submit these claims on paper.
Claim Status Inquiry
View both pending and processed claims as well as review message codes, payment dates, check numbers and more via the following:
Online Claim Adjustments
Providers may submit and track claim adjustments online using the Claim Status Inquiry (CSI) tool on Tufts Health Plan's secure Provider portal. The CSI tool allows providers to perform the following functions:
- Adjust previously submitted claims, including changing provider and payee ID numbers, procedure and diagnosis codes, billed amounts, modifiers and member information.
- Submit payment disputes by filling out an electronic form that includes the rationale for the request and allows providers to attach electronic documents for paperless submission or send supporting documents by mail.
- Return funds by selecting either a claim refund via check or a claim to have retracted from future claim payments
Electronic Remittance Advice (ERA)
Whether claims are submitted directly, through a clearinghouse, or online through MD On-Line, Tufts Health Plan offers electronic remittance from PaySpan Health, allowing providers to automatically post payments and denials for all claims.