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Office Managers Meeting Quincy, MA November 1, 2018
Office Managers Meeting
Quincy, MA
November 1, 2018
Discussion Topics
Product Overviews
Plan Identification
Provider Resource Center
Provider Website Navigation
Online Tools for Providers
Secure Provider Website
Provider News and Training
Provider Resources and Education
Division and Product OrganizationTo optimize use of our online resources, you must identify and select the Tufts Health Plan division in which the member is enrolled: Commercial Medicare
Tufts Health Plan Senior Care Options (SCO) Tufts Health Public Plans
Refer to the Products Overview and Member ID Card Guide for assistance in determining the member’s plan and the division under which the plan falls.
Tiered Network Plans
A tiered plan is one in which providers are grouped into member cost-share levels, or tiers.
The grouping is based on quality and cost, with the lowest member cost share being applied to those providers who best meet quality and cost-efficiency thresholds.
Member cost share varies by tier, with Tier 1 requiring the smallest member cost share.
For all plans, copayment, coinsurance and deductibles vary by employer group plan design.
Note: Confirm member responsibility using the Eligibility and Benefits search tool on the secure Provider website.
Tufts Health Plan’s Tiered PlansTufts Health Plan offers a variety of plans with tiered member cost share.
Your Choice
• 3-tier
• 2-tier
Navigator by Tufts Health PlanTM
Massachusetts Group Insurance Commission (GIC) Plans
• Navigator by Tufts Health PlanTM
• Tufts Health Plan Spirit
Steward Employee Choice
Lifespan Premier Choice
Tufts Health Freedom Plan
Note: Tiering methodology differs by plan type.
Tufts Health Freedom Plan and Tufts Health Plan Commercial Plans
Commercial providers may see Tufts Health Freedom Plan members. Tufts Health Freedom Plan members will have a Tufts Health Freedom Plan member ID card, and Tufts Health Plan Commercial members will have a Tufts Health Plan member ID card.
Reminder: Use Tufts Health Plan's secure Provider website to verify member eligibility, determine the member's plan type and access benefit information: tuftshealthplan.com/provider.
Key Definitions
Referral:
A referral verifies that the PCP has approved the member’s care to that provider. It is the responsibility of the PCP to indicate the number of visits and type of specialty care service approved.
Prior Authorization:
Assists the health plan to determine medical necessity and appropriateness of health care services under the applicable health care benefit plan.
Prior to patient care…
Verify patient eligibility
Confirm patient is in your panel (for PCPs)
Request or check
authorization status
Request or check referral
status
Navigating Tufts Health Plan’s Provider Website
tuftshealthplan.com/provider
Navigating Tufts Health Plan’s Website- tuftshealthplan.com/provider
Tufts Health Plan’s Provider website has two distinct sections:
Public Provider website• Medical necessity guidelines• Payment policies
• Pharmacy programs• Provider manuals• Training and education
Secure Provider website (registration required)
Tufts Health Provider Connect (Tufts Health Public Plans only)
Tufts Health Plan Provider Portal (Commercial and Senior Products)
• Claims status inquiry
• Eligibility and benefits
• Referral inquiry and submission
• Inpatient notification request submission
• Online claim adjustments
Recommended Browsers
Tufts Health Plan recommends using the latest versions of one of the following
Internet browsers for the public and secure Provider websites:
Mozilla Firefox
Google Chrome
Note: Internet Explorer is not optimal for working on the public and secure Provider websites.
Select a Division
To find the information that you need, identify which division of
Tufts Health Plan your patient’s plan is listed under.
Tufts Health Plan Commercial plans, Tufts Medicare Preferred
HMO, Tufts Health Plan SCO and Tufts Health Public Plans
require separate provider agreements
Accept patients with plans that are listed in the divisions with
which you hold provider agreements.
Always verify member eligibility.
Check the member’s ID card to determine the member’s plan.
Use the secure Provider website to verify the member’s plan.
Secure Provider Website Login- Select a Division
Secure Provider Website for Commercial and Senior Products
Claims Status Inquiry - Free Form Search You can search with any information related to the claims that
you are looking for. For example, if you are looking for a claim from July. Just type “July” in to the search box, and claims associated with the month of July will be returned.
You can search for multiple pieces of information at once. For example, you can enter many claim numbers returning multiple results. You can also enter multiple pieces of information related to a single claim in order to refine search results.
When searching for multiple pieces of information at once, simply put a comma and/or space in between your search items.
Claims Adjustment
Provider Payment Dispute Overview
Providers have the right to file a payment dispute if they disagree with a decision regarding the denial or compensation of a claim.
The Online Claim Adjustment Tool on the secure Provider website is the primary means of submitting Commercial and Senior Products claim adjustment request and payment disputes.
When submitting a payment dispute by mail, the Request for Claim Review Form, along with any supporting documentation, is required. The form can be found in the Forms section of the Resource Center at tuftshealthplan.com/provider.
A separate dispute form must be submitted for each claim adjustment.
All incomplete submissions will be returned.
For complete information, refer to the Provider Payment Dispute Policy found in the Payment Policy section of the Resource Center on the public Provider website.
Submitting Payment Disputes By Mail A separate Request for Claim Review Form, along with any supporting
documentation, is required for each claim adjustment.
Make sure to list a valid claim number, Tufts Health Plan message code andindicate the appropriate review type on the form.
Tufts Health Public Plans - Provider Payment Dispute Policy
Click on the Request for Claim Review
Mailing Information link to view the addresses to use
when mailing the Request for Claim Review Form.
Submitting Payment Disputes By Mail
A separate Request for Claim Review Form along with any supporting documentation is required for each claim adjustment.
Do not include new/original (i.e., previously unprocessed) claims with your
payment dispute forms
Payment disputes must be separated by product and denial reason, and sent to the appropriate post office box.
Do not highlight, as text may appear blacked out when scanned, which may delay processing.
Make sure to list a valid claim number and Tufts Health Plan message code.
Indicate the appropriate review type.
Appeals for denials resulting from the billing of an unlisted procedure code
must include operative notes that identify the service(s) performed associated with the unlisted code. The portion of the operative notes that identifies the unlisted service must be underlined.
Disputes of claims denied for receipt past the filing deadline must include
acceptable proof of timely submission.
Tufts Health Public Plans
Tufts Health Public Plans
Tufts Health Public Plans provide access to high-quality health care for Massachusetts and Rhode Island residents with low to moderate incomes.
Plan offerings include: Tufts Health Direct – Health Connector (A focused network plan for
individuals and small groups)
Tufts Health Together – Includes MassHealth Plans, as well as the following Accountable Care Organization (ACO) Plans (Effective 3/1/18):
Tufts Health Together with Atrius Health
Tufts Health Together with BIDCO
Tufts Health Together with Boston Children’s ACO
Tufts Health Together with CHA
Tufts Health RITogether – A RI Medicaid Plan (serving RIte Care and
Rhody Health Partners members). A separate provider agreement is needed for participation in the Tufts Health RITogether provider network.
Tufts Health Unify – OneCare Plan (Medicare-Medicaid plan)
Each ACO plan includes unique features and special programs.
Tufts Health Together ACO Member ID Cards
Tufts Health Public Plans Referral Information
PCP referral requirements apply to members in certain provider systems seeking nonemergent specialty services.
Information about referrals can be found in Chapter 2 of the Tufts Health Public Plans Provider Manual:
Specialty Services Payment Policy
The Specialty Services Payment Policy is located in the Tufts Public Plans Payment Policies section in the Resource Center on the public Provider website.
The policy includes a list of services that do not require a PCP referral.
Tufts Health Public Plans- Referrals
The chart below demonstrates the specialist referral policy applicable to Tufts Health Together – MCO and ACPP plans:
Tufts Health Public Plans - Services That Require Prior Authorization
Services from out-of-network providers
Certain covered services
Non-preferred in-network facilities, specialists and providers
Daily home health care (HHC) services or for HHC extending beyond six months in duration
Certain durable medical equipment (DME)
Certain behavioral health services
Certain drug authorizations
Advanced radiology imaging services, interventional pain management spinal surgeries and management of joint surgeries
Tufts Health Public Plans- Submitting Prior Authorization Requests Online
Submitting Prior Authorization Requests
MedHOK Portal (accessed via Tufts Health Provider Connect)
Tufts Health Together
Tufts Health Direct
Tufts Health Provider Connect Tufts Health Unify
Fax a Standardized Prior Authorization Request Form to 888.415.9055
Verifying Prior Authorizations
Ongoing status of a prior authorization:
MedHOK Portal via Tufts Health Provider Connect
Completed review decisions are available:
MedHOK Portal
NEHEN or NEHENNet
Claim Information
1. File claims through Tufts
Health Provider Connect
2. Check claim status or get
remittance advice
3. File a request for claim review
1. File claims no later than 90 days after the date of service.
Submit claims using Tufts Health Provider Connect online or on paper by mailing them to:
Tufts Health PlanP.O. Box 8115Park Ridge, IL 60068-8115
2. Check claim status by going to Tufts Health Provider Connect.
3. File a request for a claim review no later than 60 days after you receive the explanation of Payment (EOP)
You may find the “Request for Claim Review” form on our website in the Provider Resource Center.
Mail requests forms to:Tufts Health Public PlansProvider Payment DisputesP.O. Box 9194Watertown, MA 02471-9194
Secure Provider Website Login- Tufts Health Public Plans
Tufts Health Provider Connect Tufts Health Provider Connect offers online self-service tools for Tufts
Health Public Plans products.
Tufts Health Public Plans products include Tufts Health Direct, Tufts Health RITogether, Tufts Health Together and Tufts Health Unify.
Tufts Health Provider Connect- Eligibility Search
Tufts Health Provider Connect- Referral Status Inquiry
Tufts Health Provider Connect - MedHOK
MedHOKRequest and view outpatient prior authorization requests for Tufts Health Together and Tufts Health Direct Members online.
Request medical prior authorization by clicking here.
View authorizations by clicking here.
Tufts Health Provider Connect- Claim Status Search
Provider Resource Center
Tufts Health Provider Connect User Guide
MedHOK Provider Portal User Guide Inpatient notifications and prior authorization requests for outpatient
services, for Tufts Health Direct and Tufts Health Together plan members, should be entered in the MedHOK online tool through Tufts Health Provider Connect.
.
Provider Resource Center- Payment Policies
Medical Necessity Guidelines
Medical necessity guidelines are established and based on current literature review, including InterQual; consultation with practicing
physicians in the Tufts Health Plan service area, who are medical experts in the particular field; the policies of government agencies, such as the U.S. Food and Drug Administration (FDA); and standards adopted by
national accreditation organizations.
Guidelines are revised and updated annually, or more frequently as new evidence becomes available that suggests needed revisions.
Medical necessity guidelines and InterQual criteria are used in conjunction with the member’s benefit plan document and in coordination with the
provider recommending the service, drug, device or supply.
Medical Necessity Guidelines
Medical Necessity Guidelines (continued)
Find Pharmacy Information on the Provider Website
Current information regarding tier changes, online formularies, pharmacy medical necessity guidelines and descriptions of pharmacy management programs is available on the Pharmacy section at tuftshealthplan.com/provider/pharmacy.
News and Training for Providers
Provider Update - One Newsletter for all Products
Beginning with the August 1, 2018 issue, Tufts Health Plan has one combined Provider Update newsletter for all products.
The combined Provider Update will include 60-day notifications and other important business communications applicable to Commercial products, Senior Products and Tufts Health Public Plans products.
Provider Update will continue to be released on the existing schedule: February 1, May 1, August 1 and November 1.
Register to Receive Provider Update by Email
The registration form can be accessed on the public Provider website at tuftshealthplan.com/provider. Click "Register Your Email" below to complete and submit the short registration form.
Note: This email address will be used only for required notifications and other pertinent business communications. It will not change or grant login credentials to the secure Provider website.
Commercial Care Management - Fax Number Change
Beginning December 10, 2018 for Commercial members, all requests and notifications for Care Management should be faxed to the new fax number:
617.673.0329
For the following programs: Chronic Condition Management
Priority Care – Adult and Pediatric
Sirona Health
Supportive Care Management
Transition to Home
Tufts Health Priority Newborn Care
For questions, please call Commercial Provider Services at 888.884.2404
Cultural Competency Training for Tufts Health Public Plans
Providers’ Cultural Competency Training status can be reflected in our online provider directory.
Based in part on CMS’s requirements for
Tufts Health RITogether
Tufts Health Together (MCO and ACPP plans)
Tufts Health Unify
Providers can complete the Cultural Competency Attestation form on our public Provider website.
Cultural Competence* describes the ability of systems and health care professionals to provide high-quality care to patients with diverse values, beliefs and behaviors. This includes tailoring delivery to meet each individual’s social, cultural and linguistic needs.
*Definition from The Commonwealth Fund’s “Cultural Competence in Health Care Report”
Community Partners Program for Tufts Health Together Members
MassHealth has begun identifying members of Tufts Health Together for eligibility for referral to the Community Partners (CPs) Program.
CPs are organizations experienced with behavioral health (BH) or long-term services and supports (LTSSs).
CPs will partner with MCOs and ACPPs to coordinate and manage care for certain CP-eligible Tufts Health Together members.
For more on the CPs Program, visit the MassHealth website:
mass.gov/guides/masshealth-community-partners-cp- program
Update Your Practice Information
Providers are reminded to notify Tufts Health Plan of any changes to their contact or panel information, such as a change to their ability to accept new
patients, a change of street address or phone number, or any other change that affects their availability to patients.
How to Update Your Information Commercial (including Tufts Health Freedom Plan products), Tufts
Medicare Preferred HMO and Tufts Health Plan SCO Providers
If your contact/panel information is not correct on the Find a Doctor search,
please update it as soon as possible by completing the Standardized Provider Information Change Form or Tufts Health Plan’s Provider Information Change Form, available in the Provider Forms section of the
Resource Center, and returning it by fax or mail, as noted on the form.
Tufts Health Public Plans Providers
If your contact/panel information is not correct on the Find a Doctor search, please update it as soon as possible by completing the Provider Information Form for Medical Providers or for Behavioral Health Providers, available
in the Provider Forms section of the Resource Center, and returning it by fax or mail, as noted on the form.
Health and Wellness Resources for Commercial Members
Personalized support to help Commercial Members (excluding Tufts Health Freedom Plan) to optimize their health and wellness at no additional cost.
Wellbeing Assessment (WBA)
Wellness coaching
Condition Management
Nurse24SM
Members can refer to the Unlock a Healthier You information on the public Member website. tuftshealthplan.com/member
Tufts Medicare Preferred HMO plans and the Tufts Health Plan Senior Care Options (SCO) Plan earned a 5 out of 5 star rating from Medicare!
For additional information and rating details visit: tuftsmedicarepreferred.org/medicare-star-ratings
Improving Coordination of Care- Managing Care Among Different Providers
Schedule specialist appointments for the patient during or right after the PCP office visit.
Make specialist appointments easier by: Referring to specialists who offer timely appointments
Setting clinical expectations with specialists
Making sure records and reports are available to the specialist before the patient’s appointment
Referring to specialists who readily send back reports
Establish clear expectations and standards with specialists to exchange reports in a timely manor.
Visit the Institute for Health Care Improvement website at ihi.org/resources for tools, improvement measure guides, white papers and videos that offer help with improvement efforts.
Provider Training and Educationtuftshealthplan.com/provider/training- Guides and Resources
Provider Education and Training- Webinarstuftshealthplan.com/provider/training
Provider Education and Training- Office Managers Meetingstuftshealthplan.com/provider/training
Contact Information
Provider Call Centers:
• Tufts Health Plan Commercial Provider Services: 888.884.2404
• Tufts Health Public Plans Provider Services (MA): 888.257.1985
• Tufts Health Public Plans Provider Services (RI): 844.301.4093
• Tufts Health Plan Medicare Preferred and Tufts Health Plan SCO Provider Relations: 800.279.9022
Commercial and Senior Products Behavioral Health Department: 800.208.9565
EDI Operations: 888.880.8699 ext. 54042 or [email protected]
Technical Inquiries: 888.884.2404, option 6 or [email protected]
Provider Education: [email protected]
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