Last updated 4/16/2021 with formatting updates and extending Medicare sequestration through December 31, 2021.

Coronavirus (COVID-19) Updates for Providers

During the COVID-19 Public Health Emergency (PHE), Tufts Health Plan’s Pandemic Planning work group continues to meet on a regular basis to respond to changing events.  It continues to monitor and follow recommendations from the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), State Public Health Departments (Connecticut, New Hampshire, Massachusetts and Rhode Island) and other official sources on an ongoing basis.

This page contains the most up-to-date information about Tufts Health Plan's policies and coverage for all fully-insured and self-insured groups*, however, self-insured groups do have the option to opt-out of several of these policies during the PHE and those opt outs may not be specifically listed. As the PHE continues to develop, updates will be posted here. Please check back regularly.

Please note, the information posted here, including member cost sharing changes, may differ from what is reflected in the secure Provider portal. Refer to the Claims Guidelines section for additional information.

Effective Dates

Unless otherwise noted, all policies are effective beginning with dates of service on or after March 6, 2020. These policies have been put in place in connection with the COVID-19 crisis and are not intended to be permanent changes. For any policy without an end date listed or for which it states "until further notice," we continue to evaluate Tufts Health Plan policies with the state emergencies and other regulations in mind, and will aim to provide at least four week notice in advance of any termination of the policy. Coverage and policies for Tufts Health Commercial (including Tufts Health Freedom Plan and CareLinkSM ), Tufts Health Medicare Preferred HMO, Tufts Health Plan Senior Care Options (SCO), Tufts Health Public Plans (Tufts Health Direct, Tufts Health RITogether, Tufts Health Together – MassHealth MCO Plan and Accountable Care Partnership Plans [ACPPs], and Tufts Health Unify) members, unless otherwise specified, are as follows:

COVID-19 Vaccinations, Testing and Treatment

COVID-19 Vaccinations
Once a COVID-19 vaccine becomes available to members, Tufts Health Plan will cover the vaccine in full. There will be no cost to members. Refer to the COVID-19 Vaccination Payment Policy and the Coronavirus (COVID-19) Vaccination Frequently Asked Questions (FAQs) for Providers for additional information.

Tufts Health Plan complies with federal and state guidelines for vaccines. Refer to the DPH for Massachusetts, Rhode Island, and New Hampshire for information on vacccines.
COVID-19 Diagnostic Testing - Effective until further notice

The following applies to all Tufts Health Plan products:

  • Tufts Health Plan will pay 100% of the allowed amount for medically necessary testing (including, but not limited to radiology and lab tests). Click here for a list of procedure codes.
  • There will be no member cost sharing (i.e., no copays, deductible, or coinsurance) for viral and antibody testing. Providers should not collect a copay from members.
  • Testing for COVID-19 is covered when ordered or referred by a physician or appropriately licensed health care professional.
    • Tests self-ordered by members, including tests ordered through an online self-completed questionnaire, are not covered for reimbursement.
    • At home viral tests are not covered unless orderd by a physician or attending provider.
  • FDA authorized antibody testing for COVID-19 is covered only when it has been determined by a provider who has performed an individualized clinical assessment to be medically necessary to make decisions about a member's care in accordance with current CDC and state public health department guidelines, which are being continuously updated.
  • Testing is not covered if conducted solely for return-to-work or return-to-school purposes,  for public health surveillance, or for any other purpose not primarily intended for individualized diagnosis or treatment.
    • When performing any such tests, including non-diagnostic or occupational tests for return-to-work scenarios, providers should bill the appropriate laboratory code following our existing billing guidelines (e.g U0002) and use the diagnosis code.
  • Testing for asymptomatic members, including those with no known or suspected exposure to COVID-19, is covered when being admitted to a health care facility or when it has been determined by a provider who has performed an individualized clinical assessment to be medically necessary to make decisions about a member's care in accordance with current CDC and state public health department guidelines, which are being continuously updated.
  • Members are encouraged to see in-network providers, whenever possible. However, this policy applies to in-network and out-of-network (OON) providers.
In person, COVID-19 Treatment - Effective until further notice

The following applies to all Tufts Health Plan products:

  • Tufts Health Plan will reimburse providers for treatment according to covered benefits in our plans for those members positively diagnosed with COVID-19. Note: Per CMS, Senior Products and Tufts Health Unify providers on an IPPS-DRG payment will receive add-on payments for the treatment of COVID-19.
  • Tufts Health Plan will waive member cost share, including copays, for COVID-19 treatment when ICD-10 code U07.1 is present, in any position, on an Inpatient Facility claim and when ICD-10 code U07.1, Z03.818 or Z20.822 is present on an Outpatient Facility or Professional claim. Note: For Professional claims, when one of the codes noted above is billed, member cost sharing is waived for only the service lines related to COVID-19 testing/treatment.
    • ICD-10 code U07.1 was developed by the World Health Organization (WHO) and is intended to be sequenced first followed by the appropriate codes for associated manifestations when COVID-19 meets the definition of principal or first-listed diagnosis. However, if COVID-19 does not meet the definition of principal or first-listed diagnosis (e.g. when it develops after admission), then code U07.1 should be used as a secondary diagnosis. For further guidance, please refer to the official ICD-10-CM guidelines for coding encounters related to the COVID-19 coronavirus outbreak.
    • Prior to April 1, 2020, B97.29 was accepted as a positive diagnosis for COVID-19. For discharge/dates of sservice on or after September 1, 2020 this code is not accepted as a positive diagnosis for COVID-10.
  • Monoclonal antibody treatment (bamlamivimab) is covered (without utilization management) for the treatment of mild to moderate COVID-19 in adult and pediatric patients with positive COVID-19 test results who are at high risk for progressing to severe COVID-19 and/or hospitalization. Treatment is administered in the hospital outpatient setting. Senior Products member claims should be submitted to Medicare Administrative Contractors (MACs). Tufts Health Commercial and Tufts Health Public Plans products follow the standard claims submission processes.
  • Members are encouraged to see in-network providers, whenever possible. However, this policy applies to in-network and out-of-network (OON) providers.

Telehealth/Telemedicine

Temporary COVID-19 Telehealth Payment Policy

Refer to the Temporary COVID-19 Telehealth Payment Policy for the following:

Note: For dates of service after July 20, 2020, pre-COVID coverage policies and benefits (including applicable cost share) apply for out-of-network (OON) telemedicine.

Referrals and Out-of-Network Authorizations

In-Network Referral Policies – Effective until further notice
Tufts Health Plan is waiving referral requirements, until further notice, for all in-network care, regardless of diagnosis, for all Tufts Health Plan products, with the exception of Tufts Health Freedom Plan.

This temporary referral policy applies to all fully-insured and self-insured groups*, however, self-insured groups do have the option to opt-out and those opt outs may not be specifically listed. To confirm referral opt outs for self-insured groups, contact Provider Services.
Out-of-Network Authorization Policies for COVID-19 Services – Effective until further notice
If a member's plan requires a referral or authorization to received out-of-network (OON) services, Tufts Health Plan is waiving such requirements for the OON services listed below when related to a COVID-19 diagnosis regardless of member's plan type:
  • Inpatient care
  • Post-acute care, including inpatient rehab, skilled nursing facilities, long-term acute care (LTAC), and/or home care following an inpatient admission
  • Primary care or outpatient behavioral health services
  • Urgent/emergent services
Out-of-Network Authorization Policies for Non-COVID-19 Services – Effective through July 20, 2020
For dates of service after July 20, 2020, Tufts Health Plan’s pre-COVID coverage policies and benefits (including applicable cost share) will apply for out-of-network (OON) services. All plans that require a referral or authorization to receive OON services will again need to follow standard, pre-COVID procedures for receiving OON care. The only exception is for COVID-related care, for which authorization requirements continue to be waived.

Prior to July 21, 2020 the following policies were in place for OON providers:
  • If a member’s plan requires a referral or authorization to receive out-of-network (OON) services, Tufts Health Plan waived such requirements for OON services related to the following, regardless of a COVID-19 diagnosis or of member’s plan type:
    • COVID-19
    • Inpatient care
    • Post-acute care, including inpatient rehab, skilled nursing facilities, long-term acute care (LTAC), and/or home care following an inpatient admission
    • Primary care or outpatient behavioral health services
  • Plans which required referrals and/or authorizations to see OON specialists continued to require referrals and/or authorizations unless services were related to the above. Note: The referral and/or authorization requirement refers to in-person and telehealth services.
  • The in-network cost share was applied at the authorized level of benefits for all OON services listed above unless it was for a service that Tufts Health Plan was waiving cost share.
  • Tufts Health Plan reserves the right to transfer inpatient care from an OON provider to an in-network provider when the transfer can be facilitated appropriately.
  • Claims for the services above will not be denied for being OON for dates of service on or before July 20, 2020. Note: There is an industry-standard possibility that claims may deny for other unrelated and appropriate reasons.
Note: Tufts Health Plan follows regulatory guidance and/or standard processes for determining payment to OON providers.

Utilization Management

Prior Authorization and Notification Flexibility for the Diagnosis and Treatment of COVID-19 – Effective as outlined below
The following applies to all Tufts Health Plan products:
  • Diagnoses and treatments related to COVID-19 or known or suspected of having COVID-19 contraction:
    • Prior authorization is not required, including for transfers to post-acute non-hospital facilities and for home health care.
    • Effective for dates of services on or after April 1, 2021 notification is required within 2 business days of the admission.
Note: Refer to the In Person, COVID-19 Treatment section above for ICD-10 codes to be present for the diagnosis and treatment of COVID-19.
Prior Authorization Guidelines – Effective as outlined below
The following prior authorization guidelines apply to all diagnoses, except for a COVID-19 diagnosis, for which specific guidance is outlined above:
  • As a reminder, urgent/emergent admissions are never subject to prior authorization.
  • Effective for dates of service on or after April 1, 2021, prior authorization will be reinstated for non-hospital locations for post-acute care (i.e. inpatient rehab, LTAC, skilled nursing facilities and home care), including following an inpatient hospital admission.
  • Effective for dates of service on or after April 1, 2021, prior authorization requirements are reinstated for hospice services. Refer to the Hospice Services Payment Policy for Commercial, Senior Products or Tufts Health Public Plans for additional information.
With respect to prior authorization requirements for inpatient treatment or outpatient scheduled surgeries and admissions to acute care hospitals or mental health hospitals:
  • Effective for dates of service on or after April 1, 2021, review requirements (i.e., prior authorization and/or concurrent review, as applicable) will be reinstated for Massachusetts Commercial Products and Tufts Health Direct for any elective inpatient treatment or outpatient scheduled surgeries or admissions to acute care hospitals or mental health hospitals. Pre-COVID processes should be followed.
  • For all other states and product lines, standard PA requirements and processes should be followed for services occuring on or after July 1, 2020.
The following prior authorization guidelines remain in place throughout the COVID-19 emergency:
  • Sleep study prior authorization and notification requirements through eviCore healthcare (eviCore), Tufts Health Plan’s sleep benefit manager, remain in place. For more information, refer to Sleep Management Program.
  • High-tech imaging prior authorization requirements through National Imaging Associates (NIA) remain in place. For more information, refer to High-Tech Imaging Prior Authorization Program.
Prior authorization and notification is not required for the following behavioral health services:
  • Applied Behavioral Analysis (ABA) for all products
  • Children’s Behavioral Health Initiative (CBHI) for Tufts Health Together,
  • Behavioral Health for Children and Adolescents (BHCA) for Massachusetts Commercial products
  • Home-Based Therapeutic Services (HBTS) for Tufts Health RITogether
  • Psychology/Neuropsychology testing and rTMS for Rhode Island Commercial products Note: Effective for dates of service on or after June 1, 2021, prior authorization and notification is required for psych/neuropsych testing and rTMS for Rhode Island Commercial products.
Note: Providers are still responsible for confirming the service is covered by the individual treatment plan and the member meets medically necessary criteria for the service.
Inpatient Notification Guidelines – Effective as outlined below
The following inpatient notification guidelines apply to all diagnoses and are not specific to a COVID-19 diagnosis:
  • Effective for dates of service on or after April 1, 2021, notification is required within 2 business days after the date of admission.
  • Tufts Health Plan continues to require inpatient notification pursuant to standard timelines for elective non-COVID-19 admissions.
Note: Tufts Health Plan remains available to assist with discharge planning for all admissions and reserves the right to retroactively review services for medical necessity.
 
Concurrent Review – Effective as outlined below

The following concurrent review guidelines apply to all diagnoses and are not specific to a COVID-19 diagnosis:

  • Effective for dates of service on or after April 1, 2021, concurrent review requirements are reinstated for Massachusetts Commercial Products and Tufts Health Direct for all inpatient treatment (including inpatient hospice services), including behavioral health admissions at acute care hospitals or mental health hospitals. Pre-COVID processes should be followed.
  • For all other states and product lines, concurrent review requirements were reinstated for services occuring after December 31, 2020 and pre-COVID processes should be followed.
Note: Tufts Health Plan remains available to assist with discharge planning for all admissions and reserves the right to retroactively review services for medical necessity.

Claims and Billing Guidelines

Providers should contact their contract manager to request a rate for medically necessary lab testing provided by an external laboratory in accorance with the MA DOI Bulletin 2020-25.

Claims Guidelines
Tufts Health Plan is informed when CMS and state insurance agencies issue new billing and reimbursement guidelines in response to the PHE. These guidelines are reviewed by Tufts Health Plan and implemented, as appropriate. Providers should not  await billing instructions from Tufts Health Plan.

Providers should follow guidelines on this page for dates of services listed during the PHE and continue to submit claims as they currently do. For all other billing guidelines, refer to the Professional Services and Facilities Payment Policy and the benefit-specific payment policies located in the Provider Resource Center.

Unless otherwise stated, Tufts Health Plan follows industry standard coding guidelines. Refer to current coding guidelines for a complete list of ICD, CPT/HCPCS, revenue codes, modifiers and their usage.

Note: Providers may bill inpatient for services provided at alternative inpatient sites.
Billing by Certified Registered Nurse Anesthetists - Effective until further notice
The following applies to all Tufts Health Plan products:
  • Certified registered nurse anesthetists (CRNA) are not required to include the supervising physician information on claims. Note: Tufts Health Plan will continue to compensate for medically necessary CRNA services.
  • Anesthesia claims should be billed with the appropriate procedure code, modifier and applicable time units, as described in the Anesthesia Payment Policies for Commercial and Senior Products and Tufts Health Public Plans.
  • Tufts Health Plan defers to providers to determine whether physician supervision is required under the laws of the state in which they practice and/or hospital policies.
Provider Appeals, Post-Payment Billing Audits and Pre-Payment Billing Review – Effective as outlined below
The following applies to all Tufts Health Plan products, effective as outlined below:
  • The timeframe for filing provider appeals was extended by up to 90 days from Tufts Health Plan's standard appeals timeline, upon request, effective through December 31, 2020.
  • Upon request, Tufts Health Plan will provide reasonable extensions of timeframes for provider audits of hospital claims only  through March 31, 2021.
Medicare Advantage Reimbursement - Effective through December 31, 2021
CMS has extended the suspension of the sequestration payment reduction through December 31, 2021. As such, Tufts Health Plan has implemented this CMS requirement and suspended the reimbursement reductions for Medicare Advantage hospital rates and professional rates for the same time period for acute care hospitals, clinicians, physicians and PCPs. This applies to Tufts Medicare Preferred, Senior Care Options, and Tufts Health Unify.

Other Benefit Information

Behavioral Health - Effective until further notice

Department of Mental Health (DMH) Tier 1 and Tier 2 Hospital Inpatient Notification Process

Per MassHealth Managed Care Entity (MCE) Bulletin 55, MassHealth requires Tufts Health Plan to temporarily increase rates for DMH designated Tier 1  and Tier 2  hospitals that have admitted COVID-19 positive Medicaid members. In order to administer this payment increase in accordance with the Bulletin, Tufts Health Plan requires DMH designated Tier 1 and Tier 2 hospitals to have completed the Bulletin 55 Provider Attestation form and send back to Tufts Health Plan.  In addition, Tier 1 and 2 providers must complete the Behavioral Health Services Inpatient Notification Form  when admitting a COVID-19 positive Tufts Health Together MCO or ACO member, or when treating a Tufts Health Together member that has become COVID-19 positive within 96 hours of admission. Refer to the form for submission instructions.

Submitting Clinical Information

For the duration of the COVID-19 emergency, Behavioral Health providers that do not have fax capabilities can email any clinical information to the appropriate Tufts Health Plan email address, as outlined below: In the email subject line, include the product name and type of service you are emailing information about.

Additional Resources

Tufts Health Together – MassHealth MCO Plan and ACPPs
MassHealth has published the following frequently asked questions (FAQs) to support providers during the PHE: The Department of Public Health’s Bureau of Substance Addiction Services has also released guidance that has been codified in All Provider Bulletins from MassHealth and other regulatory guidance. Providers should consult the following Massachusetts Coronavirus Disease 2019 (COVID-19) - Providers pertinent regulatory guidance.

Note: This is not exhaustive of all COVID-19 regulatory guidance issued by MassHealth or other agencies nor does all listed guidance pertain to Tufts Health Together MCO and ACPPs.
Pharmacy - Effective until further notice
Commercial Products, Tufts Health Direct and Tufts Health RITogether
  • Tufts Health Plan will waive the refill limitation one-time to allow for early refills of a medication prescription prior to the expiration date, including specialty pharmaceuticals. Controlled substances are excluded from this policy.
  • Maintenance medications may be refilled for up to a 90-day supply, assuming the days supply is available based on the unused portion of the prescription.
Tufts Health Together
Senior Products and Tufts Health Unify
  • Tufts Health Plan allows early refills of a medication prescription prior to the expiration date, including specialty pharmaceuticals. Controlled substances are excluded from this policy.
  • Maintenance medications may be refilled for up to a 90-day supply, assuming the days supply is available based on the unused portion of the prescription.
Chloroquine and Hydroxychloroquine Coverage for Commercial (including Tufts Health Freedom Plans) and Tufts Health Public Plans
  • Prior authorization is required for coverage of chloroquine and hydroxychloroquine tablets for members initiating a new course of treatment. Refer to the Pharmacy Medical Necessity Guidelines for Chloroquine and Hydroxychloroquine for prior authorization requirements.
  • No action is required for members who have previously been taking these drugs.

Tips for Prescribers

For information for members on Warfarin that require international normalized ratio (INR) testing, click here.
DME, Medical Supplies and Home Health Services
In accordance with MassHealth MCE Bulletin 39, a member’s physician, nurse practitioner, physician assistant or clinical nurse specialist may:
  • Prescribe or write letters of medical necessity for DMEs and oxygen and respiratory equipment, and
  • Order home health services and establish, review, certify and recertify a member’s plan of care.

Personal Protective Equipment (PPE)

CPT code 99072 is designed for providers to report expenses incurred during a PHE, including PPE, cleaning supplies and additional clinical staff time. This code is non-reimbursable for all Tufts Health Plan products.

Credentialing

Credentialing of New Practitioners - Effective until further notice

Practitioners to Provide Services during the PHE Only

  • Practitioners seeking to provide care during the PHE only, but do not seek to join any Tufts Health Plan network on a more permanent basis, should complete the COVID-19 Deployment Only Enrollment Roster and submit to: Provider_Information_Dept@tufts-health.com for Commercial (including Tufts Health Freedom Plan), Tufts Medicare Preferred HMO, and Tufts Health Plan Senior Care Options (SCO) networks and Provider_Data_Request@tufts-health.com for Tufts Health Public Plans.
  • Include “COVID-19 Enrollment Only” in the subject line of the email containing the completed form
  • Examples of such practitioners include:
    • Retirees granted temporary licensure in order to work during the PHE
    • Recent medical student graduates who may be granted temporary licensure who are working in a hospital or facility during the PHE and have not begun their residency programs
    • Clinical fellows and clinical researchers who have been granted temporary privileges to provide care in the facility setting
    • Any out-of-network practitioners granted a temporary license to provide services in a state where Tufts Health Plan serves, and not typically their home practice state in order to work during the PHE.  Note: This category of practitioner will need to have verifications completed, including inquiry about 1135-based licensure waivers from CMS, if applicable

Practitioners Seeking to Join Tufts Health Plan Networks

  • Practitioners who seek to join Tufts Health Plan networks on a more permanent basis should follow the usual contracting and credentialing processes. Refer to the Credentialing and Contracting Overview for additional information.
  • The Tufts Health Plan Credentialing Department will make every effort to expedite the credentialing process.
If you have any questions regarding expedited credentialing or provisional credentialing, please contact Tufts_Health_Plan_Credentialing_Department@tufts-health.com. Providers may also refer to the Frequently Asked Questions to Tufts Health Plan’s Credentialing Department.
 

More Information

 

*The above applies to all fully-insured and self-insured groups. Self-insured groups do have the option to opt-out of several of these policies but must do so in writing. Because Uniformed Services Family Health Plan (USFHP) is subject to separate federal requirements, the above policies do not apply to USFHP with the exception of the policies regarding COVID-19 Diagnostic Treatment and Inpatient Notification Flexibility. Please refer to the USFHP provider portal for information regarding telemedicine billing procedures.

The above policies will be revisited on a continuing basis.

Note: Providers should follow these guidelines for the dates of services listed during the COVID-19 emergency. For all other billing guidelines, refer to the Professional Services and Facilities Payment Policy  and the benefit-specific payment policies located in the Provider Resource Center.