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.

Coding Advisor (Change Healthcare)

Products: Commercial

Coding Advisor reviews potentially irregular evaluation and management billing patterns and identifies areas for improvement based on comparison of similar specialty providers. Patterns are identified based on retrospective claims review and performs provider education and outreach in order to improve coding accuracy.

Providers will receive a letter from Change Healthcare if areas for potential improvement in billing patterns are identified. For general questions, contact Change Healthcare's customer service line at 844.592.7009.

Note: Change Healthcare has designated ReleasePoint, Inc. as its authorized representative to secure any medical records needed coding validation audits; as a result, providers may be asked to provide these medical records to ReleasePoint.

Forensic Review (Equian)
Products: Commercial

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

Equian 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).

Note: Tufts Health Plan has appointed LexiCode as the third-party inpatient coder for second-level appeals of Equian DRG validation audit findings; as a result, providers can expect to receive a letter from LexiCode regarding appeals.

For general questions about the Equian Forensic Review program, contact:
Provider Services
Phone: 888.884.2404

For questions regarding claims or review decisions, contact:
Theodore J. Abariotes
Claims Resolution Manager
Equian, LLC
600 12th Street, Suite 300
Golden, CO 80401
Email: tabariotes@equian.com
Phone: 720.903.7370 (direct)

For questions regarding appeals, contact:
Equian, LLC
Attn: Appeals Department
300 Union Blvd. Suite 200
Lakewood, CO 80228
Email: appeals@equian.com

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).