Tufts Health Plan Senior Products Provider Manual
This online Provider Manual has been developed as a reference tool for providers and office staff. It represents the most up-to-date information on the products, programs, policies, and procedures for Tufts Health Plan Senior Products, including Tufts Medicare Preferred and Tufts Health Plan Senior Care Options (SCO). This Manual sets forth the policies and procedures that providers participating in the Tufts Health Plan Senior Products network are required to follow.
Chapters
The following topics are included in the Introduction chapter:
- About the Senior Products Provider Manual
- Overview of Tufts Medicare Preferred
- Overview of Tufts Health Plan SCO
- Primary Care Providers (PCPs)
- Department Directory
The following topics are included in the Members chapter:
- Coverage Options
- Eligibility
- Enrollment
- Disenrollment
- Member Education
- Member Identification Cards
- Health Risk Assessement
- Advanced Directives
- Member Rights and Responsibilities
- Confidentiality of Protected Health Information
- Member Appeals and Grievances
The following topics are included in the Providers chapter:
- Tufts Health Plan Contracts with CMS and EOHHS
- General Responsibilities
- Provider Newsletter
- Confidentiality of Member Medical Records
- PCPs
- Specialty Care Referrals
- PCP Eligibility Report and List
- Medical Care Access Standards for Primary Care
- Outpatient Behavioral Health/Substance Use Disorder Treatment Access Standards
- Changing PCPs
- Provider Terminations and Network Changes Specialists
- Nurse Practitioners and Physician Assistants
- Aging Services Access Points and Geriatric Support Services Coordinators
- Credentialing
- Practitioners’ Rights and Responsibilities
- Hospital Credentialing
- Contracting Requirements
- Advance Directives
- Outreach
- Treatment Plan
- Communication of Clinical Information
- Discrimination Prohibited
- Provider Compliance
- Provider Rights
- Provider Marketing Activities
- MassHealth
- Eligibility Verification Process
- Provider Education
- Health Promotion and Wellness Activities Performance
The following topics are included in the Referrals, Prior Authorization and Notifications chapter:
- Referrals
- Prior Authorizations
- Notifications
The following topics are included in the Claims Requirements, Coordination of Benefits and Payment Disputes chapter:
- General Guidelines
- Electronic Data Interchange Claims
- Paper Claims
- Claims Payment
- Explanation of Payment (EOP)
- Summary of Claims in Process
- Electronic Remittance Advice (ERA)
- Claims Reports
- Retroactive Denials (Tufts Health Plan SCO)
- Corrected Claims and Disputes
- Provider Disputes
- Coordination of Benefits (COB)
- Motor Vehicle Accidents (MVA)
- Subrogation
- Claim Specifications
The following topics are included in the Member Appeals and Grievances chapter:
- Quality Improvement Organizations
- Appeals
- Grievances
The following topics are included in the Financial Programs chapter and only apply to Tufts Medicare Preferred:
- Risk Adjustment
- Reimbursement
- Pharmacy Services
- Stop Loss Reinsurance
- Settlement of Funds
- Special Member Status
- Provider Reimbursement
- PCP Capitation Report
Note: The content in this chapter does not apply to Tufts Health Plan SCO.
The following topics are included in the Medical Management chapter:
- Medical Management Program
- Medical Management Program Activities
- Utilization Review
- Urgent and Emergency Care
- Poststabilization Care
- InterQual Criteria
- Coverage Resources
The following topics are included in the Quality Administrative Guidelines chapter:
- Quality Improvement Program
- Credentialing Site Visit Requirements
- Medical Record Maintenance Procedures and Review
- Preventive Health and Clinical Practice Guidelines
- Transplants
- Serious Reportable Events
The following review types are included in the Utilization Review Determination Time Frames chapter:
- Whether to Expedite a Request for a Determination
- Part B Drug Prospective and Concurrent Expedited (Urgent)
- Non-Drug Prospective and Concurrent Expedited (Urgent)
- Concurrent Expedited (Urgent)
- Part B Drug Standard Prospective and Concurrent (Nonurgent)
- Non-Part B Drug Standard Prospective and Concurrent (Nonurgent)
- Retrospective Review
- Review Resulting in the Reduction, Suspension, or Termination of a Previously Authorized Service
Tufts Health Plan’s observation program was introduced to ensure that medically necessary care is provided in the most appropriate setting. For additional information, refer to the Observation Program chapter.
The following topics are in the Care Model for Tufts Health Plan SCO chapter:
- Interdisciplinary Care Team (ICT)
- Care Management Process
- Assessment and Risk Categories
- Features of the Tufts Health Plan SCO Care Model
Note: This chapter does not apply to Tufts Health Medicare Preferred HMO.
The following topics are in in the Aging Services Access Points and Long-Term Service Supports chapter and only apply to Tufts Health Plan SCO:
- Aging Services Access Points (ASAPs) and Geriatric Support Services Coordinators (GSSCs)
- Long-Term Service Supports (LTSS)
Note: This chapter does not apply to Tufts Medicare Preferred HMO.