Last updated 10/6/2021: Waiving COVID-19 treatment cost share for Rhode Island Commercial members has been extended through October 30, 2021, due to the extension of the Rhode Island State of Emergency
Coronavirus (COVID-19) Updates for Providers
During the COVID-19 Public Health Emergency (PHE), Tufts Health Plan has adapted policies and business operations to support members receiving care and to aid providers in ensuring patients can safely access the care they need. Tufts Health Plan 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.
As states lift emergency orders, Tufts Health Plan is returning to pre-COVID-19 operations and policies. 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.
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 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 as outlined in the Medical Necessity Guidelines for COVID-19 Antibody (Serological) Testing.
- 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.
COVID-19 Treatment - Effective as outlined below
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 is reinstating member cost share, including copays, for COVID-19 treatment as outlined below:
- Tufts Medicare Preferred HMO and Tufts Health Freedom Plan: Effective for dates of service on or after August 7, 2021
- Rhode Island Commercial products: Effective for dates of service on or after October 31, 2021, unless otherwise extended by state orders
- Massachusetts Commercial products and Tufts Health Direct: Effective for dates of service on or after September 30, 2021 for outpatient and observation claims billed with diagnosis code Z03.818
- Tufts Health Plan will continue to waive member cost share, including copays, for COVID-19 treatment as outlined below:
- Rhode Island Commercial products: through October 30, 2021, unless otherwise extended by state orders when ICD-10 code U07.1 is present, in any position, on an Inpatient Facility claim or 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.
- Massachusetts Commercial and Tufts Health Direct: In accordance with Massachusetts Division of Insurance Bulletin 2021-08 and the diagnosis codes therein.
- Tufts Health Plan covers medically necessary monoclonal antibody treatment in outpatient settings, without prior authorization as per the FDA's EUA criteria, 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. Refer to monoclonal antibody treatment information from CMS and CDC for details on limitations of authorized use and instructions for healthcare providers.
- 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.
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 as outlined below
Tufts Health Plan is waiving referral requirements for all in-network care, regardless of diagnosis, for Senior Products, Tufts Health Together and Tufts Health Unify through the end of the federal PHE.
For all other products, referral requirements have been reinstated and pre-COVID-19 processes should be followed. For more information, refer to the Referral, Prior Authorization and Notification Policy
Out-of-Network Authorization Policies for COVID-19 Services – Effective as outlined below
If a member's plan requires a referral or authorization to received out-of-network (OON) services, Tufts Health Plan has reinstated such requirements for the OON services listed below when related to a COVID-19 diagnosis for all plans with the exception of Massachusetts Commercial products, Tufts Health Direct, Tufts Health Together and Tufts Health Unify:
- 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
Prior Authorization Guidelines – Effective as outlined below
Prior authorization requirements for treatments related to COVID-19 or known or suspected of having COVID-19 contravtion will be reinstated as outlined below:
- Tufts Health Freedom Plan, Rhode Island Commercial plans and Senior Products: Effective for dates of service on or after August 7, 2021
- Tufts Health RITogether: Effective for dates of service on or after October 1, 2021
Prior authorization treatment of COVID-19 for Massachusetts Commercial plans, Tufts Health Direct, Tufts Health Together and Tufts Health Unify will continue to be waived in accordance with Massachusetts Division of Insurance Bulletin 2021-08.
For all other services, unrelated to the diagnosis and treatment for COVID-19, prior authorization requirements are in effect, for all Tufts Health Plan products and pre-COVID-19 processes should be followed, with the exception of Tufts Health RITogether. Tufts Health RITogether continues to waive prior authorization for medical services through September 30, 2021 and Behavioral Health services through December 31, 2021.
As a reminder, urgent/emergent admissions are never subject to prior authorization.
Inpatient Notification and Concurrent Review
- Notification is required within 2 business days after the date of admission for all diagnoses and are not specific to a COVID-19 diagnosis.
- Concurrent review requirements are reinstated 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.
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
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.
Personal Protective Equipment
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 lines of business.
Billing by Certified Registered Nurse Anesthetists - Through the end of the Federal PHE
The following applies to all Tufts Health Plan products through the end of the federal PHE:
- 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.
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.
Effective September 17, 2021, dispensing of Ivermectin tablets is limited to 20 tablers within 90 days for Commercial, Tufts Health Direct, Tufts Health RITogether and SCO products. Requests to exceed quantity limits will be approved for FDA-approved indications or those supported by compendia only. Requests to exceed quantity limitations for experimental or investigational use will be denied.
Senior Products and Tufts Health Unify
The following Senior Products and Tufts Health Unify policies are in effect through the end of the Federal PHE:
- 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.
Tips for Prescribers
For information for members on Warfarin that require international normalized ratio (INR) testing, click here.
Credentialing of New Practitioners
COVID-19 Policies History
- October 6, 2021: Waiving COVID-19 treatment cost share for Rhode Island Commercial members has been extended through October 30, 2021, due to the extension of the Rhode Island State of Emergency
- September 24, 2021: COVID-19 treatment and prior authorization guidelines updated for Massachusetts products in accordance with Massachusetts Division of Insurance Bulletin 2021-08, Ivermectin quantity limitation information and Medical Necessity Guidelines for COVID-19 Antibody (Serological) Testing
- September 9, 2021: Continuing to waive COVID-19 treatment cost share for Rhode Island Commercial members through October 2, 2021 due to the extension of the Rhode Island State of Emergency
- August 27, 2021: Clarified coverage of monoclonal antibody treatment; removed previously end dated credentialing and pharmacy policies
- August 10, 2021: Waiving cost share for COVID-19 treatment has been extended through September 5, 2021 for Rhode Island Commercial Products due to the extension of the Rhode Island State of Emergency
- July 30, 2021: Reinstating member cost share for Massachusetts Commercial and Tufts Health Direct members when diagnosis code Z03.818 is billed, effective for dates of service on or after September 30, 2021; removed Behavioral Health policies with July 15, 2021 end date
- July 26, 2021: Removed billing information for diagnosis code B97.29, information for Bulletin 2020-23, DME, medical supplies and home health services; added end dates for CRNA and Senior Products and Tufts Health Unify pharmacy policies, clarified prior authorization policies
- July 9, 2021: Revised prior authorization information; waiving medical prior authorization through September 30, 2021 and Behavioral Health prior authorizations through December 31, 2021 for Tufts Health RITogether and reinstating prior authorization for non-hospital locations for post-acute care for dates of service on or after August 7, 2021 for Tufts Health Together
- June 17, 2021: Reinstating cost share for COVID-19 treatment for Tufts Health Freedom Plan members, effective for dates of service on or after August 7, 2021; Referrals continue to be waived for in-network services Tufts Health Together for the duration of the federal PHE
- June 14, 2021: Rhode Island Commercial products continue to waive in-network referrals and behavioral health prior authorizations for certain services through July 9, 2021; Alternative submission of clinical information for Behavioral Health services effective through July 15, 2021; Pharmacy policies for Commercial products, Tufts Health Direct and Tufts Health RITogether and Credentialing policies for all products effective through August 7, 2021
- June 10, 2021: Reinstatement of the following policies, effective for dates of service on or after August 7, 2021: referrals for Tufts Health Together, any required authorizations for COVID-19 treatment, including for out-of-network providers, for all products with the exception of Massachusetts plans, any required prior authorization for non-hospital locations for post-acute care for Commercial Products, Tufts Health Direct, Tufts Health RITogether, and Tufts Health Medicare Preferred HMO
- June 7, 2021: Reinstating cost share for COVID-19 treatments for Rhode Island Commercial products and Tufts Medicare Preferred HMO, effective for dates of service on or after August 7, 2021
- June 1, 2021: Reinstatement of referral requirements for all Commercial products; effective for dates of service on or after July 1, 2021
- May 13, 2021: Prior authorization is no longer required for chloroquine and hydroxychlorine, effective for dates of service on or after June 1, 2021;
- May 5, 2021: Reinstatement of prior authorization for behavioral health services in Massachusetts, effective June 1, 2021 and for Rhode Island products, effective July 1, 2021, unless otherwise extended by state orders
- April 20, 2021: Bamlanivimab is not covered when administered alone, effective for dates of service on or after April 16, 2021
- March 19, 2021: Revised COVID-19 testing requirements; prior authorization and notification is required for psych/neuropsych testing and rTMS for Rhode Island Commercial products; effective for dates of service on or after June 1, 2021
- March 2, 2021: Inpatient notification is required within 2 business days of admissions, prior authorization is required for non-hospital locations for post-acute care and hospice services, effective for dates of service on or after April 1, 2021
- February 3, 2021: COVID-19 Treatment cost share is waived when the appropriate diagnoses are listed on the claim.
- January 26, 2021: Tufts Health Plan will provide reasonable extensions of timeframes for provider audits of hospital claims through March 31, 2021
- December 11, 2020: Revised telehealth billing for Tufts Health RITogether
- November 30, 2021: Coverage for monoclonal antibody treatment; CPT code 99072 in non-reimbursable
- November 6, 2020: Reinstatement of copays for non-COVID-19 related telehealth services, effective for dates of service on or after January 1, 2021
- September 30, 2020: Revised policy effective dates for concurrent review (December 31, 2020), prior authorization is suspended for any inpatient treatment or outpatient scheduled surgeries or admissions to acute care hospitals or mental health hospitals for Massachusetts Commercial Products and Tufts Health Direct (December 31, 2020), provider appeals (effective through December 31, 2020) and audits for hospital claims (Orthonet program resumes October 1, 2020; Forensic Review will resume January 1, 2021)
- September 22, 2020: Revised telehealth billing guidelines
- August 17, 2020: Added additional CPT codes for COVID-19 testing and updated guidance for B97.29 and U07.1
- August 12, 2020: Testing coverage for asymptomatic members; OON authorization policies for COVID-19 services
- August 6, 2020: Rapid testing is covered when determined to be medically necessary
- July 24, 2020: Clarified concurrent review policies effective through September 30, 2020
- July 16: 2020: Timeframe for filing appeals is extended up to 90 days, upon request through September 30, 2020; added codes for COVID-19 testing; clarified COVID-19 testing policies and added new COVID-19 testing codes
- July 10, 2020: Reinstating cost share and coverage for OON services, unrelated to COVID-19 diagnosis or treatment, standard claims submissions and timely filing policies, effective for dates of service on or after July 20, 2020; ART policy flexibilities and pre-payment billing review and post payment billing audit changes effective until July 20, 2020 concurrent review suspension for post-acute and urgent/emergent admissions through September 30, 2020
- June 29, 2020: Updated billing guidance for behavioral health telehealth claims
- June 22, 2020: Providers have 180 from date of determination to request a peer-to-peer (Orthonet) and 90 days from the date of determination to appeal (Forensic Review)
- June 17, 2020: Added language clarifying home testing kits, or other tests self-ordered by members, are not covered for reimbursement
- June 12, 2020: Added billing guidelines for Adult Day Health Providers for Tufts Health Unify and Senior Care Options
- June 10, 2020: Reinstatement of concurrent review for dates of service on or after July 20, 2020; reinstatement of prior authorization for elective non-COVID-19 admissions for dates of service on or after July 20, 2020
- April 21, 2020: Suspending the reimbursement reduction for Medicare Advantage
- April 13, 2020: Member plans requiring referrals or authorizations for out-of-network (OON) is waived for certain services; added credentialing content; extending ART cycles
- April 10, 2020: Timeframe for filing appeals has been extended by 90 days from standard appeals timelines; added prepayment billing review and post-payment billing audit content, effective through June 1, 2020; added policy for assisted reproductive technology (ART)
- March 27, 2020: Added coverage for hydroxychloroquine
- March 24, 2020: Added POS and modifiers for telehealth billing
- March 18, 2020: COVID-19 Updates for Providers page created; included COVID-19 testing and treatment policies; telehealth policies; pharmacy and authorization flexibilities
*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.