Last updated 7/10/2020 with policy and coverage end dates.

Coronavirus (COVID-19) Updates for Providers

During the rapidly evolving situation around COVID-19, 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 pertaining to COVID-19. As the COVID-19 situation 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.

Tufts Health Plan is aware that some Commercial (including Tufts Health Freedom Plan) telehealth claims may not yet be processing in accordance with policies put in place in response to COVID-19. Claims billed with POS 02 for dates of service between March 6, 2020 and June 27, 2020, paid at a lower rate and in some instances, also applied a cost share. These claims will be reprocessed, and providers can expect payment in July. Once we have an exact date on when providers can expect payment, we will post notification to this page. Please call Provider Services with any additional questions.

Attention Behavioral Health Providers
If you submitted telehealth claims without POS 02 or telehealth modifier, and/or without all other appropriate modifiers (including those that indicate license and/or service level) you will need to submit corrected telehealth claims. For future reference, please refer to our telehealth billing guidelines on this page.

Effective Dates

Unless otherwise noted, all policies are effective beginning with dates of service starting 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 weeks notice in advance of any termination to 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 Diagnostic Testing and Treatment

Tufts Health Plan is following the National Uniform Billing Committee recommendation regarding the usage of appropriate hospital bill types, main hospital address and National Provider Identifier (NPI) for diagnostic testing and specimen collection locations at off-campus facilities, such as parking lots, tents, and football stadiums.

COVID-19 Laboratory 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 lab testing:
    • Microbiological testing (CPT code 87635) Note: The AMA CPT Editorial Panel approved the new, specific CPT code 87635. For more information, refer to the CPT Assistant AMA Fact Sheet.
    • CDC testing (HCPCS U0001)
    • Non-CDC testing (HCPCS U0002)
    • Immunoassay (CPT 86328)
    • Antibody (CPT 86769)
    • High-throughput technologies for infectious agent detection (HCPCS U0003)
    • High-throughput non-CDC (HCPCS U0004)
    • Specimen collection (HCPCS G2023)
    • Specimen collection by an individual in a skilled nursing facility (SNF) or by a laboratory on behalf of a Home Health Agency (HCPCS G2024)
  • There will be no member cost sharing (i.e., no copays, deductible, or coinsurance). Providers should not collect a copay from members.
  • Testing, including antibody testing, is covered when determined by a PCP or other treating provider to be medically necessary in accordance with current CDC and state public health department guidelines, which are being continuously updated. Note: COVID-19 testing may be ordered by any state-authorized health care professional for Tufts Medicare Preferred HMO, Senior Care Options (SCO) and Tufts Health Unify. Tufts Health Plan will continue to update this guideline as new guidance is issued.
  • Home testing kits, or other tests that are self-ordered by members, are not covered for reimbursement.
  • 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 Other 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 other medically necessary diagnostic testing (including, but not limited to radiology and other lab tests).
  • There will be no member cost sharing (i.e. no copays, deductible, or coinsurance). Providers should not collect a copay from members.
  • 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 (Confirmed Positive Diagnosis) - 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.
  • There will be no member cost sharing (i.e. no copays, deductible or coinsurance). Providers should not collect a copay from members. This applies to all in-person treatment regardless of place of service, including inpatient and skilled nursing facility (SNF) services. Note: This applies to all services (i.e., medications, DME, etc.) provided at the appointment by the provider.
  • Tufts Health Plan will affirm a positive diagnosis with the presence of the following diagnosis codes:
    • ICD-10 code U07.1 is used as a primary diagnosis.
    • ICD-10 code B97.29 is used as either a primary diagnosis or a secondary diagnosis appended to a respiratory illness.
  • 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 (Initially Suspected, But Without Confirmed Positive Diagnosis) - 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 for whom COVID-19 is suspected but without a positive diagnosis of COVID-19.
  • There will be no member cost sharing (i.e., no copays, deductible or coinsurance).  Providers should not collect a copay from members. This applies to all in-person treatment regardless of place of service, including inpatient and SNF services. Note: This applies to all services (i.e., medications, DME, etc.) that are provided at the appointment by the provider.
    • Tufts Health Plan will affirm a non-positive diagnosis with the absence of ICD-10 code U07.1 as a primary diagnosis.
    • Tufts Health Plan will affirm a non-positive diagnosis with the absence of ICD-10 code B97.29, used as either a primary diagnosis or a secondary diagnosis appended to a respiratory illness.
    • Tufts Health Plan may further affirm a non-positive diagnosis with the presence of ICD-10 code Z03.818, which denotes a ruled-out COVID-19 diagnosis.
    • Tufts Health Plan may further affirm a non-positive diagnosis with the presence of ICD-10 code Z20.828, which denotes exposure but no confirmed COVID-19 diagnosis.
  • 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

Telehealth/Telemedicine Guidelines
The following telehealth/telemedicine policy has been implemented for all Tufts Health Plan products to prevent members from needing to leave their home to receive care. This policy applies for all diagnoses and is not specific to a COVID-19 diagnosis.
 
  • Beginning July 20, 2020 pre-COVID-19 coverage and cost share will apply for out-of-network (OON) telemedicine. Until then, the policies in this section will apply. In-network telehealth guidelines will remain in place until further notice.
  • Tufts Health Plan will compensate in-network providers at 100% of their contracted rate for services rendered in person, as specified in provider agreements, until further notice. The telehealth reduction will not apply.
  • OON providers will be reimbursed using Tufts Health Plan's standard processes for reimbursing OON claims. Members are encouraged to see in-network providers, wherever possible. However, this policy applies to in-network and OON providers.
  • Plans which require referrals and/or authorizations to see OON specialists continue to require referrals and/or authorizations for telehealth services, unless services are related to the following:
    • 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
  • All Tufts Health Plan contracting providers, including specialists and urgent care facilities, may provide telemedicine services to members for all medical (well visits/preventive, sick visits, preadmission screenings), behavioral health, ancillary health and home health care visits (i.e. skilled nursing, PT, OT and ST) for both new and existing patients. Prior authorization is not required.
  • Tufts Health Plan will waive member cost share for both in-network and OON telehealth services.  This includes both facility and professional services. Providers should not collect a copay from members. As noted above, beginning July 20, 2020 pre-COVID-19 coverage and cost share will apply for OON telemedicine.
  • Telehealth also includes telephone consultation. Note: For Medicare products, under CMS rules, special codes already exist for certain telephonic services and those codes will be paid at the CMS fee schedule.
  • Documentation requirements for a telehealth service are the same as those required for any face-to-face encounter, with the addition of the following:
    • A statement that the service was provided using telemedicine or telephone consult;
    • The location of the patient;
    • The location of the provider; and
    • The names of all persons participating in the telemedicine service or telephone consultation service and their role in the encounter.
  • Services covered under telehealth should be clinically appropriate and not require in-person assessment and/or treatment.  Tufts Health Plan defers to the provider to make this determination.
  • Note for Behavioral Health Providers: There are no restrictions on service type, including individual and group behavioral health services. Additionally, the usage of audio without video is acceptable.
Note: Providers do not need to use Teladoc to provide services to our members. As previously communicated, Teladoc is an additional benefit available to Commercial members.
 
Billing Guidelines
  • Providers must submit professional claims in accordance with applicable state and federal requirements and, at a minimum, bill with place of service (POS) 02 OR the appropriate telehealth modifiers.
    • Providers may submit claims with the POS they would have reported had the service been rendered in person, as well as the appropriate procedure codes and telehealth modifiers. Note: Claims submitted with POS 02 will continue to process with the appropriate in person rate.
    • Providers should continue to bill with the appropriate license-level modifier as specified in the applicable payment policy.
  • For facility claims, providers should submit the appropriate Revenue Code, CPT/HCPCS code(s) and modifier(s).
  • Refer to the Claims Submission and Timely Filing section below for additional billing guidelines.
Note: Telehealth modifiers are not required for Behavioral Health claims for Senior Care Options (SCO),  Tufts Health Together (MassHealth MCO Plan and Accountable Care Partnership Plans), and Tufts Health Unify.
 
Modifiers Modifier Description Modifier Definition
95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. The totality of the communication of information exchanged between the physician or other qualified health care professional and patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. Modifier 95 may only be appended to the services listed in Appendix P. Appendix P is the list of CPT codes for services that are typically performed face-to-face but may be rendered via real-time (synchronous) interactive audio and video telecommunications system.
GT Via interactive audio and video telecommunication systems Modifier used to indicate telehealth services. Except for demonstrations in Alaska and Hawaii, all telehealth must be interactive.
GQ Via asynchronous telecommunications system Modifier used to indicate telehealth services. Except for demonstrations in Alaska and Hawaii, all telehealth must be interactive.
G0 Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke None provided


 

Utilization Management

Referrals and Out-of-Network Authorizations - In-Network policies in effect until futher notice; Out-of-network policies for services unrelated to COVID-19 diagnosis or treatment end on July 20, 2020
The following applies to all Tufts Health Plan products, with the exception of Tufts Health Freedom Plan:
  • Tufts Health Plan is waiving all referral requirements for in-network care, effective until further notice.
  • If a member's plan requires a referral or authorization to receive out-of-network (OON) services, Tufts Health Plan is waiving such requirements for OON services related to the following, regardless of member's plan type, effective until July 20, 2020:
    • 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
  • Tufts Health Plan is waiving the referral requirement for the above services related or unrelated to a COVID-19 diagnosis.
  • The in-network cost share will be applied at the authorized level of benefits for all OON services listed above unless it is for a service that Tufts Health Plan is waiving cost share, effective until July 20, 2020.
  • Plans which require referrals and/or authorizations to see OON specialists continue to require referrals and/or authorizations unless services are related to the above. Note: The referral and/or authorization requirement refers to in-person and telehealth services.
  • Notification is still required as outlined in the Prior Authorization and Notification Flexibility section.
  • 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. Note: There is an industry-standard possibility that claims may deny for other unrelated and appropriate reasons.
  • Tufts Health Plan will follow regulatory guidance and/or standard processes for determining payment to OON providers.
Prior Authorization and Notification Flexibility - Effective through September 30, 2020 unless otherwise noted 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: (presence of ICD-10 codes U07.1, B97.29, Z03.818, and/or Z20.828):
    • Prior authorization is not required.
    • Notification is required within 5 days after the date of admission.

The following applies to all diagnoses and not specific to a COVID-19 diagnosis:

  • Post-acute admissions:
    • Prior authorization is not required for inpatient rehab, LTAC, skilled nursing facilities, and home care following an inpatient hospital admission.
    • Notification is required within 5 days after the date of admission.
    • Concurrent review is suspended for all post-acute hospital inpatient services through September 30, 2020.
    • All other post-acute policies remain unchanged.
  • Urgent/emergent inpatient admissions:
    • Tufts Health Plan is relaxing admission notification requirements for urgent/emergent inpatient admissions by requiring notification within 5 days after the date of admission.
    • Concurrent review is suspended for all urgent/emergent hospital inpatient services through September 30, 2020.
  • Elective non-COVID-19 admissions:
    • Prior authorization requirements are suspended for any scheduled surgeries or admissions at hospitals through July 1, 2020. All prior authorization requirements and concurrent review will be reinstated for services occurring after July 1, 2020, with the exception of Massachusetts Commercial Products and Tufts Health Direct, for which such requirements will not be reinstated until October 1, 2020 due to the issuance of Massachusetts Division of Insurance Bulletin 2020-21.
    • Tufts Health Plan continues to require inpatient notification.
  • Hospice services:  Prior authorization or notification is not required.
  • Behavioral Health services: Refer to the behavioral health section below.
  • Sleep Studies: 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.

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

Tufts Health Plan is aware that some Commercial (including Tufts Health Freedom Plan) telehealth claims may not yet be processing in accordance with policies put in place in response to COVID-19. Claims billed with POS 02 for dates of service between March 6, 2020 and June 27, 2020, paid at a lower rate and in some instances, also applied a cost share. These claims will be reprocessed, and providers can expect payment in July. Once we have an exact date on when providers can expect payment, we will post notification to this page. Please call Provider Services with any additional questions.

Attention Behavioral Health Providers
If you submitted telehealth claims without POS 02 or telehealth modifier, and/or without all other appropriate modifiers (including those that indicate license and/or service level) you will need to submit corrected telehealth claims. For future reference, please refer to our telehealth billing guidelines on this page.

Claims Guidelines
Tufts Health Plan is informed when CMS and state insurance agencies issue new billing and reimbursement guidelines in response to the COVID-19 emergency. These guidelines are reviewed by Tufts Health Plan and implemented, as appropriate.

Tufts Health Plan has been making changes to our operating systems as decisions or regulations have been released. Most of the system changes for COVID-19 have been made and were completed on May 18, 2020. Most impacted claims rendered between March 6, 2020 and May 18, 2020 were automatically reprocessed.

Providers should follow guidelines on this page for dates of services listed during the COVID-19 emergency and continue to submit claims as they currently do. Providers should not  await billing instructions from Tufts Health Plan. 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.
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.
Claims Submission and Timely Filing - Effective until July 20, 2020

The following applies to all Tufts Health Plan products, until July 20, 2020. All claims submissions and timely filing policies, outlined in the Provider Manuals for Commercial, Senior Products, and Tufts Health Public Plans will be reinstated for services occuring after July 20, 2020.

  • The filing deadline for inital claims submission for all products is 180 days from the date of service or date of discharge. Note: This filing extension does not apply to pharmacy claims.
  • Providers may bill inpatient for services provided at alternative inpatient sites.
  • The timeframe for filing appeals has been extended by 90 days from Tufts Health Plan's standard appeals timeline.
  • Tufts Health Plan is providing extended timeframes for audits while Massachusetts is in a state of emergency.
Pre-Payment Billing Review and Post-Payment Billing Audit - Effective until July 20, 2020
The following changes will be effective April 8, 2020 until July 20, 2020:
 

Pre-Payment Billing Review Programs

Record requests:
  • New requests: No new requests will be issued beginning April 8, 2020
  • Claims denied prior to April 8, 2020 for failure to produce documentation will remain denied until documentation is provided to the appropriate vendor. Vendors will complete reviews and issues findings per existing processes.
In process reviews:
  • Vendors will complete reviews and issue findings per existing processes.
  • Providers may appeal, as indicated below.
Appeals:
  • Orthonet: Providers have up to 180 days from the date of determination to request a peer-to-peer. Providers may appeal the peer-to-peer determination to Tufts Health Plan.
  • Forensic Review: Providers will have 90 days from the date of the determination to appeal to the vendor.

Post-Payment Billing Review Programs

Record requests
  • New requests:
    • Vendors will continue to request records per existing processes.
    • Providers will have 90 days from the date of the initial request to submit records.
  • Outstanding requests (i.e., record requests to which the provider has not responded): Providers will have 90 days from the date of the initial request to submit records.
  • Second request timeframes will remain the same.
  • Tufts Health Plan reserves its right to request previously agreed-upon numbers of records. If fewer records are requested from April 8, 2020 to June 1, 2020, Tufts Health Plan may increase the number of records requested in subsequent months by a commensurate amount.
In-process Reviews
  • Vendors will complete reviews and issue findings per existing processes.
  • Providers may appeal, as indicated below.
Appeals
  • In-process appeals: Vendors will complete previously-submitted appeals and issue findings per existing processes.
  • New appeals: Providers will have 90 days from the date of the determination to submit new appeals.
  • Providers will have 90 days from the date of the appeal determination to submit second-level appeals.

Fraud Investigation

Tufts Health Plan reserves the right to conduct medical record reviews during the aforementioned time frame if there is an indication of potential fraud, waste or abuse.
 
Medicare Advantage Reimbursement
In accordance with the Coronavirus Aid, Relief, and Economic Security (CARES) Act, CMS has suspended sequestration from May 1, 2020 through December 31, 2020. As such, Tufts Health Plan is implementing this CMS requirement and suspending 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.
Senior Care Options (SCO) SNF Long-Term Care Reimbursement Changes
Tufts Health Plan previously sent a letter communicating changes to SCO long-term care reimbursement, effective May 1, 2020. Due to the COVID-19 emergency, Tufts Health Plan is postponing these changes until further notice. Tufts Health Plan will provide 60-day notification prior to implementing the requirement for SNF providers to complete and submit a Management Minutes Questionnaire (MMQ) covering the long-term care stay to Tufts Health Plan in order to receive reimbursement.
Billing Guidelines for Adult Day Health Providers for Tufts Health Unify and Senior Care Options
Tufts Health Plan implemented Temporary Retainer Payments pursuant to the EOHHS Managed Care Entity (MCE) Bulletin 27, for dates of service between April 1, 2020 and June 30, 2020 for Adult Day Health (ADH) providers for Tufts Health Unify and Senior Care Options (SCO) members.

Retainer payments will be paid on a per-member, per-day basis at 100% of the provider’s contracted per diem rate for ADH services where the provider has met the eligibility criteria as outlined in MCE Bulletin 27.

In order to receive retainer payments, providers must submit a per diem claim for a member for each day on which that member would have been scheduled to attend the provider’s ADH program. Claims must be submitted using one of the two appropriate codes listed in the table below and must include the modifier U6. Claims submitted without modifier U6 will be rejected.
 
Code Modifier Description
S5102 TG U6 Complex level of care (per diem)
S5102 U6 Basic level of care (per diem)
 
Additionally, for Tufts Health Unify only, providers must submit the encounter log to unifyltss@tufts-health.com no later than the 15th of the following month. This log will be used to validate claims submitted in accordance with the eligibility requirements for retainer payment. ADH providers contracted through Aging Service Access Points (ASAPs) should provide the log to the ASAP no later than the 15th of the following month.


 

Other Benefit Information

Behavioral Health
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.
 

Prior Authorization and Notification

Prior authorization and notification is not required for the following 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: Providers are still responsible for confirming the service is covered by the individual treatment plan and the member meets medical necessity criteria for the service.

Additional Resources

Tufts Health Together – MassHealth MCO Plan and ACPPs
MassHealth has published the following frequently asked questions (FAQs) to support providers during the COVID-19 emergency:
  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

The following applies to all Tufts Health Plan products:

  • Tufts Health Plan will allow early refills of a medication prescription prior to the expiration date, including specialty pharmaceuticals. 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. Controlled substance drugs are excluded from this policy. Note: Tufts Health Together members may obtain a 90-day supply for all prescription drugs.
  • Tufts Health Plan has extended pharmacy authorizations expiring through June 30, 2020 for an additional 90 days from the original expiration date.
  • Due to drug shortages, Tufts Health Plan has made some brand alternative albuterol inhalers temporarily available. Providers should write ‘covered by plan’ on albuterol inhalers, unless a specific product is medically necessary, to allow the flexibility in dispensing a product on-hand. Note: Pharmacies may contract providers to facilitate the switch of the products are not AB-rated and automatically substitutable.
  • If vaccine for COVID-19 is developed, Tufts Health Plan will provide 100% coverage. Members will have no cost sharing responsibility.
Chloroquine and Hydroxychloroquine Coverage for Commercial (including Tufts Health Freedom Plans) and 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)
  • 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. Note: Coverage is limited to 28 tablets for approval related to COVID-19.
  • No action is required for members who have previously been taking these drugs.
Tufts Health Together – MassHealth MCO Plan and ACPPs
In accordance with MassHeath MCE Bulletin 22, prior authorization is not required for the following drugs and drug classes for members of Tufts Health Together:
 
  • Aminoglycoside agents – inhaled
  • Antibiotics – oral and injectable
  • Antifungals – oral and injectable
  • Respiratory agents – oral and inhaled
  • Sublocade™
Additionally, the following brand albuterol sulfate inhalers are covered without prior authorization: Proair® HFA, Proventil® HFA, and Ventolin® HFA.
 
Tufts Health RITogether

In response to recent shortages of albuterol inhalers, the following brand albuterol sulfate inhalers are covered without prior authorization: ProAir® HFA, Proventil® HFA, and Ventolin® HFA. Additionally, generic Proventil® HFA (albuterol sulfate) and generic levalbuterol tartrate (Xopenex HFA®).

Tips for Prescribers

For information for members on Warfarin that require international normalized ratio (INR) testing, click here.
Assisted Reproductive Technology (ART) - Effective until July 20, 2020
The following applies to all Tufts Health Plan products until July 20, 2020:
  • Tufts Health Plan will extend authorized cycles and testing intervals for members receiving infertility treatments, including but not limited to intra-uterine (IUI), in vitro fertilization (IVF) and frozen embryo transfer (FET). This is limited to one cycle (inclusive of a canceled cycle). Updated labs are not required for coverage of the previously approved cycles. Note: Prior authorization for infertility services and testing intervals valid as of March 5, 2020 are extended for cycle initiations that occur no later than August 1, 2020 or the expiration date of the valid authorization, whichever is later, regardless of the age of the infertile female at the time of cycle initiation.
  • Tufts Health Plan will not count a canceled cycle, due to COVID-19 exposure, illness or factors outside a provider’s control, towards a member’s lifetime maximum cycle limit for all products where ART services are a covered benefit with lifetime limits. Note: These situations will be reviewed on a case-by-case basis.
  • Requests for infertility services, including but not limited to IUI, IVF and FET after July 20, 2020 follow Tufts Health Plans standard processes and infertility services medical necessity guidelines for Massachusetts, Rhode Island and New Hampshire  products. This includes coverage criteria for women of advanced maternal age.

 


Credentialing

Credentialing of New Practitioners

Practitioners to Provide Services during the COVID-19 Public Health Emergency Only

  • Practitioners seeking to provide care during the COVID-19 public health emergency 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 COVID-19 public health emergency
    • Recent medical student graduates who may be granted temporary licensure who are working in a hospital or facility during the COVID-19 public health emergency 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 COVID-19 public health emergency.  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. Go to the Provider Resource Center, choose the network(s) you wish to join, then click on Credentialing + Contracting under Forms.
  • 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.