Senior Products Provider Manual

This manual provides Senior Products (Tufts Medicare Preferred HMO and Tufts Health Plan Senior Care Options [SCO]) network providers and their office staff with details on the structure, policies and procedures of Tufts Health Plan. Providers and their office staff are required to read, abide by, and reference this manual as necessary. The following chapters are included in the Senior Products Provider Manual:

Introduction

The following topics are included in the Introduction chapter:

About the Senior Products Provider Manual
Overview of Tufts Medicare Preferred HMO
Overview of Tufts Health Plan SCO
Primary Care Providers (PCPs)
Department Directory

Members

The following topics are included in the Members chapter:

Coverage Options
Eligibility
Enrollment
Disenrollment
Member Education
Member Identification Cards
Health Risk Assessement
Advanced Directives
Member Rights and Responsibilities
Confidentiality of Protected Health Information
Member Appeals and Grievances

Providers

The following topics are included in the Providers chapter:

Tufts Health Plan Contracts with CMS and EOHHS
General Responsibilities
Provider Update
Confidentiality of Member Medical Records
PCPs
Specialty Care Referrals
PCP Eligibility Report and List
Changing PCPs
Provider Terminations and Network Changes Specialists
Nurse Practitioners and Physician Assistants
Aging Services Access Points and Geriatric Support Services Coordinators
Credentialing
Practitioners’ Rights and Responsibilities
Hospital Credentialing
Contracting Requirements
Advance Directives
Outreach
Treatment Plan
Communication of Clinical Information
Discrimination Prohibited
Provider Compliance
Provider Rights
Provider Marketing Activities
MassHealth
Eligibility Verification Process
Provider Education
Health Promotion and Wellness Activities Performance

Referrals, Prior Authorizations and Notifications

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

Referrals
Prior Authorizations
Notifications

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 Guidelines
Electronic Data Interchange Claims
Paper Claims
Claims Payment
Explanation of Payment (EOP)
Summary of Claims in Process
Electronic Remittance Advice (ERA)
Claims Reports
Retroactive Denials (Tufts Health Plan SCO)
Corrected Claims and Disputes
Provider Disputes
Coordination of Benefits (COB)
Motor Vehicle Accidents (MVA)
Subrogation
Claim Specifications

Member Appeals and Grievances

The following topics are included in the Member Appeals and Grievances chapter:

Quality Improvement Organizations
Appeals
Grievances

Financial Programs for Tufts Medicare Preferred HMO

The following topics are included in the Financial Programs chapter and only apply to Tufts Medicare Preferred HMO:

Risk Adjustment
Reimbursement
Pharmacy Services
Stop Loss Reinsurance
Settlement of Funds
Special Member Status
Provider Reimbursement
PCP Capitation Report

Note: The content in this chapter does not apply to Tufts Health Plan SCO.

Medical Management

The following topics are included in the Medical Management chapter:

Medical Management Program
Medical Management Program Activities
Utilization Review
Urgent and Emergency Care
Poststabilization Care
InterQual Criteria
Coverage Resources

Quality Administrative Guidelines

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

Quality Improvement Program
Medical Care Access Goals for Primary Care
Credentialing Site Visit Requirements
Medical Record Maintenance Procedures and Review
Outpatient Behavioral Health/Substance Use Disorder Treatment Access Standards
Preventive Health and Clinical Practice Guidelines
Transplants
Serious Reportable Events

Utilization Review Determination Time Frames

The following review types are included in the Utilization Review Determination Time Frames chapter:

Whether to Expedite a Request for a Determination
Part B Drug Prospective and Concurrent Expedited (Urgent)
Non-Drug Prospective and Concurrent Expedited (Urgent)
Concurrent Expedited (Urgent)
Part B Drug Standard Prospective and Concurrent (Nonurgent)
Non-Part B Drug Standard Prospective and Concurrent (Nonurgent)
Retrospective Review
Review Resulting in the Reduction, Suspension, or Termination of a Previously Authorized Service

Observation Program

Tufts Health Plan's observation program was introduced to ensure that medically necessary care is provided in the most appropriate setting. For additional information, refer to the Observation Program chapter.

Care Model for Tufts Health Plan SCO

The following topics are in the Care Model for Tufts Health Plan SCO chapter:

Primary Care Team (PCT)
Care Management Process
Assessment and Risk Categories
Features of the Tufts Health Plan SCO Care Model

Note: This chapter does not apply to Tufts Health Medicare Preferred HMO.

Aging Services Access Points and Long-Term Service Supports

The following topics are in in the Aging Services Access Points and Long-Term Service Supports chapter and only apply to Tufts Health Plan SCO:

Aging Services Access Points (ASAPs) and Geriatric Support Services Coordinators (GSSCs)
Long-Term Service Supports (LTSS)

Note: This chapter does not apply to Tufts Medicare Preferred HMO.

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