Claim Edits

All products

October 30, 2020  

Drugs and Biologicals

Effective for dates of service on or after January 1, 2021, Tufts Health Plan will implement additional claim edits for drugs and biologicals. These edits apply to Commercial products (including Tufts Health Freedom Plan), Tufts Medicare Preferred HMO, Tufts Health Plan Senior Care Options (SCO) and Tufts Health Public Plans products. Tufts Health Plan’s policies regarding drugs and biologicals are derived from evaluation of drug manufacturers’ prescribing information and the following sources:

  • AMA’s CPT Manual
  • CMS and CMS HCPCS Level II Manual
  • FDA
  • ICD Manual
  • Medical Journals
  • Micromedex® and DRUGDEX®
  • National Comprehensive Cancer Network Drugs & Biologics CompendiumTM
  • National Government Services Inc. website
  • Pharmaceutical Compendium

These policies support appropriate diagnosis codes, indications, dosages and frequencies. In some instances, off-label indications will also be allowed where there is evidence of efficacy.

This information is documented in the drugs and biologicals payment policies for Commercial and Senior Products and Tufts Health Public Plans products.

Critical Care and Telemedicine

Effective for dates of service on or after January 1, 2021, Tufts Health Plan will implement critical care and telemedicine claim edits. These edits apply to Commercial products (including Tufts Health Freedom Plan), Tufts Medicare Preferred HMO, Tufts Health Plan Senior Care Options (SCO) and Tufts Health Public Plans products. These claim edits are derived from CMS, AMA’s CPT Manual, HCPCS, ICD-10, nationally accredited societies and Tufts Health Plan payment policies.

These edits are documented in the applicable Tufts Health Plan payment policies available in the Resource Center on the public Provider website.