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2019

Commercial

Provider Manual

2019 Commercial Provider Manual 1 Table of Contents

Table of Contents

Introduction ................................................................................................... 2

CareLinkSM ..................................................................................................... 5

Pharmacy Program ......................................................................................... 9

Members ..................................................................................................... 13

Providers ..................................................................................................... 17

Referrals, Authorizations and Notifications ....................................................... 26

Claim Requirements, Coordination of Benefits and Payment Disputes .................. 36

Quality Administrative Guidelines ................................................................... 54

Utilization Management Guidelines .................................................................. 63

Utilization Review Determination Time Frames ................................................. 73

Imaging Privileging Program .......................................................................... 78

2019 Commercial Provider Manual 2 Introduction

INTRODUCTION

Purpose of This Manual

Tufts Health Plan developed this manual to supply our providers and their office staff with details on certain

products, policies, and procedures of Tufts Health Plan. The Commercial Provider Manual applies to Commercial1 products (including Tufts Health Freedom Plan). Tufts Health Plan requires that providers and their staff read, abide by, and reference this manual as necessary.

For more information on Tufts Health Plan Senior Products or Tufts Health Public Plans policies and procedures, refer to the 2019 Senior Products or Tufts Health Public Plans provider manuals.

Overview of Tufts Health Plan

Tufts Health Plan is designed to arrange for comprehensive health care services to its members and encourage

appropriate treatment and efficient use of medical services in the provider’s office. Tufts Health Plan offers eligible employer groups and individual enrollees a range of products and plan designs. Refer to the Plans section of the public Provider website for overviews of products.

Directory of Departments

When contacting Tufts Health Plan, use the following directory or the Contact Information for Providers page to identify the most appropriate department to call.

Department Contact Responsibility

Care Management

Inpatient Manager 888.766.9818 Concurrently reviews Tufts Health Plan members

admitted to inpatient facilities Coordinates and authorizes discharge plans,

including rehabilitation, skilled nursing facility (SNF) or chronic hospital placement, home

health care, home therapies, and durable

medical equipment (DME)

Specialty inpatient

manager 888.766.9818 Facilitates discharge planning

Provides ongoing coordination of services through the continuum of illness of medically complex cases

Acts as plan liaison for members, families, providers and vendors of ancillary services

Manages complex cases

Performs out-of-network hospital reviews and discharge planning

Manages high-risk obstetrics, pediatrics, neonatology, transplants, HIV/AIDS, disabilities, rehabilitation nursing, and oncology cases

Behavioral Health Department

Behavioral Health outpatient clinical

coordinator and service representative

800.208.9565 Manages requests for outpatient behavioral health and substance use disorder (BH/SUD)

services Coordinates members’ access to inpatient

BH/SUD services

1 Commercial products include HMO, POS, PPO, Tufts Health Freedom Plan, and CareLinkSM when Tufts Health Plan is the primary

administrator.

2019 Commercial Provider Manual 3 Introduction

Department Contact Responsibility

Behavioral Health care manager

800.208.9565 Facilitates discharge planning for members hospitalized at designated facilities (DFs)

Monitors quality of care at behavioral health DFs

Precertification Operations Department

Precertification

Operations clinical staff 617.972.9409 (fax) Conducts utilization management review of

outpatient services that require prior authorization, including, but not limited to, elective surgeries, medical benefit medications, procedures

Inpatient admissions coordinator

617.972.9590 (fax) or 800.843.3553 (fax)

Processes inpatient admission notification requests for Commercial members and provides inpatient notification reference number, if applicable

Liability and Recovery

Coordination of Benefits (COB)

617.972.1098 Investigates and verifies dual health coverage Determines primary and secondary coverage

Investigates and verifies workers’ compensation claims

Adjusts coordination of benefits, workers’ compensation, and Tufts Health Plan Medicare Complement (TMC) claims

Network Management and Contracting

Network Contracting and Performance Management (NCPM)

800.442.0422, ext. 52169

Contract Manager

Negotiates contracts with provider organization leadership

Contract Specialist

Ensures contract terms are implemented in appropriate Tufts Health Plan systems

Fosters and maintains provider network relationship

Associate Contract Specialist

Processes operational changes

Allied Health Contracting 617.972.9411 Negotiates and administers contracts for all

ancillary services, including but not limited to skilled nursing facilities, inpatient rehabilitation hospitals, and home care services

Evaluates prospective ancillary providers and assesses need for additions and changes to the contracting provider network

Monitors contract compliance and performs

utilization review of contracts

Provider Information 888.306.6307 Facilitates change of provider practice or payment information status

Facilitates provider terminations

Provider Credentialing 888.306.6307 Processes new credentialing and recredentialing applications for providers and certain ancillary providers

Provider Services

Provider Services 888.884.2404 Providers should call this number for the following issues:

Inquiries regarding paid or in-process claims Interpretation of member benefits

2019 Commercial Provider Manual 4 Introduction

Department Contact Responsibility

Provider Communications and Education

Provider Education 888.306.6307, option 7

Provider_Education@tufts-health.com

Inform providers about products, policies and procedures, and online self-service options for

providers. Offers the following educational programs: Online self-service training Webinars Quarterly office managers meetings Customized on-site meetings

Claims

EDI Operations 888.880.8699, ext. 54042

Makes inquiries concerning electronic claims files Sets up electronic services

2019 Commercial Provider Manual 5 CareLinkSM

CARELINKSM

Tufts Health Plan and Cigna have partnered together to offer CareLink, an open-access health plan that provides both in-network and out-of-network benefits. No referrals are needed for specialty care, although prior authorization (precertification) and/or inpatient notification requirements may apply. CareLink members have access to the Tufts Health Plan provider network in Massachusetts and Rhode Island, and the Cigna provider network in the remaining 48 states.

CareLink is offered to eligible mid-sized employer groups residing in each service area and provides nationwide access to over 900,000 providers and 6,000 facilities. Tufts Health Plan contracting providers in Massachusetts and Rhode Island participate in the CareLink offering and are available to provide health care services for CareLink members at the in-network level of benefits. In states other than Massachusetts and Rhode Island, Cigna-contracting providers may provide in-network covered services for CareLink members.

For providers in Massachusetts and Rhode Island who have agreements with both Tufts Health Plan and Cigna,

the terms of the Tufts Health Plan provider agreement apply. Similarly, the Cigna agreement applies to services

provided to CareLink members by contracting providers outside Massachusetts and Rhode Island.

The administrative services for CareLink accounts are shared between Tufts Health Plan and Cigna; however, one payer serves the primary administrator role for each CareLink account sold. The primary administrator performs the majority of the functions associated with administering the plan for the employer group, including benefits and claims adjudication.

The primary administrator for CareLink accounts is responsible for:

Sales and overall account management/employer reporting (enrollment files and ID card distribution) Enrollment and premium billing Claims receipt, processing and adjudication Member services Provider services (except for disputes related to contractual issues, which would be resolved by the

health plan holding the contract with the provider)

General Information

The CareLink offering covers appropriately authorized, medically necessary covered services at the in-network and out-of-network level of benefits, subject to the applicable cost share.

Members are not required to select a primary care provider (PCP); as such, referrals are not required for specialty care services. Members may have a cost share differential for services performed by a PCP versus

services performed by a specialist.

Prior authorization (precertification) and/or inpatient notification requirements apply for certain procedures and/or diagnoses. For additional information, refer to the CareLink Prior Authorization List on the Tufts Health Plan website or contact Cigna directly at 800.CIGNA24 (800.244.6224) to identify specific services that have authorization/notification requirements.

CareLink members are easily identified by the CareLink logo on the front of the ID card. The Tufts Health Plan and Cigna logos may appear on the ID cards and the employer group may be listed. Refer to the Working with

CareLink grid for more information on how to determine the member’s primary administrator.

Shared Administration

CareLink—Shared Administration is offered specifically to unions and Allied Trade employer groups. Tufts Health Plan, Cigna and the union office share administrative functions (e.g., claims processing [Tufts Health Plan]),

medical management (Cigna) and claims payment (Shared Administration employer group). CareLink Shared Administration members have access to the Tufts Health Plan provider network in Massachusetts and Rhode Island, and the Cigna provider network in the remaining 48 states. The member identification number is a nine-