Tufts Health Public Plans Provider Manual

Tufts Health Public Plans developed the Public Plans Provider Manual to supply providers and their office staff with details on certain products, policies and procedures of Tufts Health Public Plans. The Public Plans Provider Manual applies to Tufts Health Public Plans products. The following topics are included in the Tufts Health Public Plans Provider Manual:

Introduction

The Introduction chapter includes information about Tufts Health Public Plans Provider Manual and an overview of Tufts Health Public Plans.

Tufts Health Unify

Tufts Health Unify is Tufts Health Public Plans' One Care plan for individuals between 21 and 64 years of age. Refer to the Tufts Health Unify chapter for more information about:

Model of Care
Enrollment and member transitions
Care management
Coordination of care
Provider training
Tufts Health Unify provider responsibilities
Tufts Health Unify member rights and responsibilities
Tufts Health Unify coverage decisions, grievances and appeals
Tufts Health Unify pharmacy program

Note: Refer to other chapters of the Tufts Health Public Plans Provider Manual for information not covered in this chapter.

Providers

The following topics are included in the Providers chapter:

Clinical Responsibilities
Provider Newsletter
PCP Responsibilities
Provider Access Standards
Other Administrative Responsibilities
Covered Services Lists
Summary of the Credentialing Process
Fraud and Abuse Policy

Referrals, Prior Authorizations and Notifications

To help ensure the quality of member care, Tufts Health Public Plans is responsible for monitoring authorization, medical appropriateness, and cost efficiency of services rendered. Refer to the Referrals, Prior Authorization and Notifications chapter for information about:

Referrals
Prior Authorizations
Inpatient Notification

Claims Requirements, Coordination of Benefits and Dispute Guidelines

The following topics are covered in the Claims Requirements, Coordination of Benefits and Dispute Guidelines chapter:

General Guidelines
Methods for Claim Submission
Coordination of Benefits
Claims Payment
Requests for Claim Review
Corrected Claims
Filing Deadline
Filing Deadline Adjustments
Provider Payment Disputes
Payment Adjustments
Member Responsibility
Claims Specifications

Utilization Management Guidelines

Tufts Health Public Plans’ utilization management (UM) guidelines are intended to help providers plan and manage care in an efficient manner with high quality standards. Refer to the Utilization Management Guidelines chapter for information about:

Utilization Management Program
Medical Necessity Guidelines
Outpatient Services Review
Appealing a Denied Request for Coverage
Inpatient Hospital Review Process
Initial Determinations
Discharge Planning
Concurrent Review and Expedited Coverage Authorizations
Provider Inquiry
Retrospective Review Policy
Continuity of Care for Massachusetts Products
Continuity of Care and Transitioning Between Out-of-Network and In-Network Providers (Tufts Health RITogether)

Care Management

Tufts Health Public Plans’ integrated care management services are intended to support the delivery of person-centered, coordinated activities to support Members’ goals and better health outcomes. The following topics are covered in the Care Management chapter:

Overview of Integrated Care Management Services
Complex Care Management Services
Disease Management Program
Health Needs Assessment
Maternal and Child Health Program
Massachusetts-Specific Care Management Services and Programs
Rhode Island-Specific Care Management Services and Programs

Behavioral Health

Tufts Health Public Plans’ behavioral health team assists with accessing varying levels of services for members based on their needs, intensity of utilization and/or coexisting medical conditions. Although many of the Behavioral Health Programs and Services are similar for Massachusetts and Rhode Island, there are some significant differences. Be sure refer to the appropriate state-specific information in the Behavioral Health chapter as outlined in the following sections:

Massachusetts and Rhode Island Behavioral Health Program
Massachusetts-Specific Behavioral Health Program
Massachusetts-Specific Behavioral Health services
Rhode Island-Specific Behavioral Health services

Quality

Tufts Health Public Plans is committed to working with providers to continuously improve the quality of health care provided to members. Refer to the Quality chapter for information about:

Quality Improvement Program
Clinical Practice Guidelines
Pay for Performance
Patient Safety
Delegation

Pharmacy

The following topics are outlined in the Pharmacy chapter:

Pharmacy Benefit
Pharmacy Prior Authorization
Limitations
Medicare Part D (Massachusetts)
Specialty Pharmacy

Rights and Responsibilities

Refer to the Rights and Responsibilities chapter for the following information:

Provider Termination
Member Grievances, Appeals, Rights and Responsibilities
Member Grievances
Member Appeals
Member Rights and Responsibilities
Permissible Marketing Activities

For more information on Tufts Health Plan Commercial products or Tufts Health Plan Senior Products policies and procedures, refer to the Commercial or Senior Products Provider Manuals.