Tufts Health Plan Commercial Provider Manual
This online Provider Manual has been developed as a reference tool for providers and office staff, and represents the most up-to-date information on Tufts Health Plan’s Commercial products, programs, policies, and procedures. This Manual sets forth the policies and procedures that providers participating in the Tufts Health Plan Commercial network are required to follow.
Chapters
The following topics are covered in the Introduction chapter:
- About the Commercial Provider Manual
- Overview of Tufts Health Plan
- Department Directory
The following topics are covered in the CareLink chapter:
- General Information
- Shared Administration
- Claims Submission
- Authorization Requirements
- Inpatient Notification
- Prior Authorization
- Transplants
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
- CareLinkSM
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
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
- Medical Care Access Standards for Primary Care Offices
- Behavioral Health/Substance Use Disorder Treatment Access Standards
- 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
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
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
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)
- Provider Site Visit Requirements
- Medical Records
- Preventive Health and Clinical Practice Guidelines
- Serious Reportable Events
Tufts Health Plan’s utilization management (UM) guidelines are intended 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
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)
The following topics are included in the Imaging Privileging Program chapter:
- Imaging Privileges for Nonradiologists
- Specialty-Specific Privileging Tables
- Service-Specific Certifications