Commercial Provider Manual

Tufts Health Plan developed this manual to supply our providers and their office staff with details on certain products, policies, and procedures of Tufts Health Plan. The Commercial Provider Manual applies to Commercial products. Tufts Health Plan requires that providers and their staff read, abide by, and reference this manual as necessary. The following chapters are included in the Commercial Provider Manual:

Introduction

The following topics are covered in the Introduction chapter:

About the Commercial Provider Manual
Overview of Tufts Health Plan
Department Directory

CareLink

The following topics are covered in the CareLink chapter:

General Information
Shared Administration
Claims Submission
Authorization Requirements
Inpatient Notification
Prior Authorization
Transplants

Pharmacy Program

The following topics are covered in the Pharmacy Programs chapter:

Tufts Health Plan Pharmacy Programs
Prior Authorization Programs
Designated Specialty Pharmacy Programs
Designated Specialty Infusion Program for Drugs Covered Under the Medical Benefit
Utilization Review Process
CareLink^SM

Members

The following topics are covered in the Members chapter:

New Members
Members' Rights and Responsibilities
Confidentiality of Protected Health Information
Patient Self Determination Act
Member Appeals Process
Member Grievance (Complaint) Process

Providers

The following topics are included in the Providers chapter:

General Responsibilities
Uniformed Services Family Health Plan (USFHP)
Provider Newsletter
Fraud, Waste and Abuse
Confidentiality of Member Medical Records
Medical Record Charges
Quality Improvement Activities
Primary Care Providers
Specialist Providers
Physician Reviewer
Nurse Practitioners and Physician Assistants
Practitioner Treatment of Self and Family Members
Chaperones for Office Examinations
Summary of the Credentialing Process
Practitioners' Rights and Responsibilities
Hospital Credentialing

Referrals, Prior Authorizations and Notifications

The following topics are included in the Referrals, Prior Authorizations and Notifications chapter:

Overview
Referrals
Outpatient Prior Authorizations
Prior Authorizations through Approved Vendors
Intermediate Level of Care Notification
Inpatient Notification

Claims Requirements, Coordination of Benefits and Payment Disputes

The following topics are included in the Claims Requirements, Coordination of Benefits and Payment Disputes chapter:

General Payment Information
Payment of Claims
Electronic Data Interchange
Receipt of Claims
Paper Claim Submission Requirements
Billing Requirements for Hospital Outpatient Services
Eligibility Inquiry
Online Adjustment Requests
Explanation of Payment
Electronic Remittance Advice
Claims Follow-Up
Filing Deadline Policy
Provider Compensation/Reimbursement Disputes
Coordination of Benefits
Miscellaneous Billing Tips and Guidelines
Claims Specifications

Quality Administrative Guidelines

The following topics are included in the Quality Administrative Guidelines chapter:

Quality Improvement Program
National Committee for Quality Assurance (NCQA)
Healthcare Effectiveness Data and Information Set (HEDIS)
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Medical Care Access Goals for Primary Care Offices
Provider Site Visit Requirements
Medical Records
Behavioral Health/Substance Use Disorder Treatment Access Standards
Preventive Health and Clinical Practice Guidelines
Serious Reportable Events

Utilization Management Guidelines

Tufts Health Plan's utilization management (UM) guidelines are intented to help providers manage care in an efficient manager with high quality standards. Refer to the Utilization Management Guidelines chapter for information about:

Role of Plan Provider
Utilization Management Program
Medical Necessity and Clinical Criteria
Medical Technology Assessment Process
Access and Coverage System for Medical Affairs Department Physicians
Role of Provider Unit Physician Reviewers (Massachusetts)
Outpatient Services Review
Retrospective Code Review
Behavioral Health Intermediate Levels of Care Service Review
Inpatient Services Review
Medical Care Management and Discharge Planning
Behavioral Health Care Management and Discharge Planning
Referral to BH Case Management Programs
Data Requirements: Clinical Information
Determinations of Coverage
Reconsideration
Commercial Condition Management Programs
Behavioral Health Care Management Programs
Transition to Home Program
Behavioral Health and Medical Integration Program
Emergency Department Aftercare Program
Substance Use Transitions Program
Emergency Services
Definition
Emergency Services “Prudent Layperson” Standards

Utilization Review Determination Time Frames

The purpose of the Utilization Review Determination Time Frames chapter is to reference utilization review (UR) determination time frames. It is not meant to completely outline the UR determination process. The following review types are covered in this chapter:

Prospective (Pre-Service) Review of Non-Urgent Services
Prospective (Pre-Service) Review of Urgent Services
Concurrent Review of Urgent Services
Retrospective (Post-Service)

Imaging Privileging Program

The following topics are included in the Imaging Privileging Program chapter:

Imaging Privileges for Nonradiologists
Specialty-Specific Privileging Tables
Service-Specific Certifications

For more information on Tufts Health Plan Senior Products or Tufts Health Public Plans policies and procedures, refer to the Senior Products or Tufts Health Public Plans provider manuals.