Tufts Health Plan Vendor Information

Tufts Health Plan works with vendors to review certain types of claims and/or authorizations for medical services, devices, and/or items.

Note: This is not an all-inclusive list.

Forensic Review (Equian)

Products: Commercial

Effective for dates of service on or after June 1, 2017.

Forensic Review is a prepayment itemized bill review service that applies condition-specific medical and financial expertise to review high-dollar inpatient claims for the following:

Unbundling
Experimental/plan language benefit
Billing errors
Incorrect charges
Insufficient descriptions
Incorrect bill types
“Never events”
Level of care discrepancies

Providers may receive emails from forensicreviewrequest@tufts-health.com regarding inquiries including but not limited to itemization requests, determination summaries, and requests for more information (RFMI).

For general questions about the Forensic Review program, contact Provider Services at 888.884.2404

For questions regarding claims or review decisions, contact:
Claims Resolution
Equian, LLC
600 12th Street, Suite 300
Golden, CO 80401
Email: claimsresolution@equian.com
Phone: 888.895.2254 (direct)

For questions regarding first level appeals, contact:
Equian, LLC
Attn: Claim Disputes
600 12th Street, Suite 300
Golden, CO 80401
Email: reconsiderations@equian.com
Fax: 866.700.5769

All second level appeals can be submitted through Tufts Health Plan’s secure Provider portal or mailed to:
Provider Payment Disputes
P.O. Box 9190
Watertown, MA 02471-9190

OrthoNet

Products: Commercial

OrthoNet conducts pre-payment reviews of certain specialist professional claims including, but not limited to, musculoskeletal, cardiology, dermatology, urology, general surgery, plastic surgery, otolaryngology, oral and/or maxillofacial. Claims for which supporting medical records have been requested will be pended in the Tufts Health Plan systems during OrthoNet’s review process.

Providers may receive requests for medical records from OrthoNet on behalf of Tufts Health Plan. All requested documentation should be submitted directly to OrthoNet at the address below.

OrthoNet Medical Services Department
P. O. Box 5015, White Plains, NY 10602
Phone: 844.489.6645
Fax: 844.546.5416

DRG Validation Program/Clinical Chart Validation Program (Cotiviti Healthcare)

Products: Tufts Medicare Preferred HMO, Tufts Health Plan SCO

Cotiviti Healthcare reviews medical charts for correct coding and proper documentation to determine whether claims are supported, and whether care was delivered in accordance with industry standards and payer guidelines.

Providers may be contacted by Cotiviti to validate information billed on a claim. Cotiviti Healthcare (on behalf of Tufts Health Plan) will notify the provider with its intent to audit.

Notification will occur within the time frame indicated in the provider’s agreement with Tufts Health Plan, absent any indication of fraud, as noted in the DRG Validation of Inpatient Hospitals Policy (Senior Products).

For questions or concerns contact Cotiviti Provider Services at 770.379.2165 Monday to Friday 8 a.m. to 5 p.m. EST/EDT.

Prior Authorization Programs for High-Tech Imaging, Spinal Conditions Management, Cardiac and Joint Surgery (National Imaging Associates)

Products: For specific product inclusions for each program, refer to the program pages below

National Imaging Associates (NIA) reviews medical necessity and provides prior authorizations on behalf of Tufts Health Plan for select outpatient and inpatient services in the following categories:

Providers may be contacted by NIA by phone, fax and/or letter as part of the prior authorization process. To obtain/verify authorizations or access medical necessity guidelines, log in to RadMD or call 866.642.9703 (Tufts Health Plan products) or 800.207.4209 (Tufts Health Public Plans products).