Tufts Health Public Plans Provider Manual

The Introduction chapter includes information about Tufts Health Public Plans Provider Manual and an overview of Tufts Health Public Plans.

Tufts Health One Care is Tufts Health Public Plans’ One Care plan for individuals between 21 and 64 years of age. Refer to the Tufts Health One Care chapter for more information about:

• Model of Care
• Enrollment and member transitions
• Care management
• Coordination of care
• Provider training
• Tufts Health One Care provider responsibilities
• Tufts Health One Care member rights and responsibilities
• Tufts Health One Care coverage decisions, grievances and appeals
• Tufts Health One Care pharmacy program

Note: Refer to other chapters of the Tufts Health Public Plans Provider Manual for information not covered in this chapter.

The following topics are included in the Providers chapter:

• Clinical Responsibilities
• Provider Newsletter
• PCP Responsibilities
• Provider Access Standards
• Other Administrative Responsibilities
• Covered Services Lists
• Summary of the Credentialing Process
• Fraud and Abuse Policy

To help ensure the quality of member care, Tufts Health Public Plans is responsible for monitoring authorization, medical appropriateness, and cost efficiency of services rendered. Refer to the Referrals, Prior Authorization and Notifications chapter for information about:

• Referrals
• Prior Authorizations
• Inpatient Notification

The following topics are covered in the Claims Requirements, Coordination of Benefits and Dispute Guidelines chapter:

• General Guidelines
• Methods for Claim Submission
• Coordination of Benefits
• Claims Payment
• Requests for Claim Review
• Corrected Claims
• Filing Deadline
• Filing Deadline Adjustments
• Provider Payment Disputes
• Payment Adjustments
• Member Responsibility
• Claims Specifications

Tufts Health Public Plans’ utilization management (UM) guidelines are intended to help providers plan and manage care in an efficient manner with high quality standards. Refer to the Utilization Management Guidelines chapter for information about:

• Utilization Management Program
• Medical Necessity Guidelines
• Outpatient Services Review
• Appealing a Denied Request for Coverage
• Inpatient Hospital Review Process
• Initial Determinations
• Discharge Planning
• Concurrent Review and Expedited Coverage Authorizations
• Provider Inquiry
• Retrospective Review Policy
• Continuity of Care for Massachusetts Products
• Continuity of Care and Transitioning Between Out-of-Network and In-Network Providers (Tufts Health RITogether)

Tufts Health Public Plans’ integrated care management services are intended to support the delivery of person-centered, coordinated activities to support Members’ goals and better health outcomes. The following topics are covered in the Care Management chapter:

• Overview of Integrated Care Management Services
• Complex Care Management Services
• Disease Management Program
• Health Needs Assessment
• Maternal and Child Health Program
• Massachusetts-Specific Care Management Services and Programs
• Rhode Island-Specific Care Management Services and Programs

Tufts Health Public Plans’ behavioral health team assists with accessing varying levels of services for members based on their needs, intensity of utilization and/or coexisting medical conditions. Although many of the Behavioral Health Programs and Services are similar for Massachusetts and Rhode Island, there are some significant differences. Be sure to refer to the appropriate state-specific information in the Behavioral Health chapter as outlined in the following sections:

• Massachusetts and Rhode Island Behavioral Health Program
• Massachusetts-Specific Behavioral Health Program
• Massachusetts-Specific Behavioral Health services
• Rhode Island-Specific Behavioral Health services

Tufts Health Public Plans is committed to working with providers to continuously improve the quality of health care provided to members. Refer to the Quality chapter for information about:

• Quality Improvement Program
• Clinical Practice Guidelines
• Pay for Performance
• Patient Safety
• Delegation

The following topics are outlined in the Pharmacy chapter:

• Pharmacy Benefit
• Pharmacy Prior Authorization
• Limitations
• Medicare Part D (Massachusetts)
• Specialty Pharmacy

Refer to the Rights and Responsibilities chapter for the following information:

• Provider Termination
• Member Grievances, Appeals, Rights and Responsibilities
• Member Grievances
• Member Appeals
• Member Rights and Responsibilities
• Permissible Marketing Activities