Last updated: 4/3/2020 with clarification to the Telehealth/Telemedicine and Prior Authorization and Notification Flexibility sections.

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.

Where can I find more information?

This page contains the most up-to-date information about Tufts Health Plan's policies and coverage pertaining to COVID-19. Please note, this information, including member cost sharing changes, may differ from what is reflected in the secure Provider portal. As the COVID-19 situation continues to develop, updates will be posted here. Please check back regularly.

Unless otherwise noted, effective for dates of services on or after March 6, 2020 until June 1, 2020*, coverage 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 is as follows:

COVID-19 Laboratory Diagnostic Testing
  • Tufts Health Plan will pay 100% of the allowed amount for medically necessary microbiological testing (CPT code 87635), which includes CDC testing (HCPCS U0001) and non-CDC testing (HCPCS U0002). Note: The AMA CPT Editorial Panel approved the new, specific CPT code 87635. For more information, refer to the CPT Assistant AMA Fact Sheet.
  • Tufts Health Plan will cover these costs in full without member cost sharing (i.e. no copays, deducticle, or coinsurance).
  • For members on closed network plans, Tufts Health Plan will cover these costs in full at in-network providers and with out-of-network providers if a member has trouble accessing such services in-network.
    • In such a case, Tufts Health Plan will hold the member harmless from a financial perspective when using an out-of-network provider.
COVID-19 Other Diagnostic Testing
  • Tufts Health Plan will pay 100% of the allowed amount for medically necessary other diagnostic testing (including, but not limited to radiology and other lab tests).
  • Tufts Health Plan will cover these costs in full without member cost sharing (i.e. no copays, deductible, or coinsurance).
  • For members on closed network plans, Tufts Health Plan will cover these costs in full at in-network providers and with out-of-network providers if a member has trouble accessing such services in-network.
    • In such a case, Tufts Health Plan will hold the member harmless from a financial perspective when using an out-of-network provider.
COVID-19 Treatment (Confirmed Positive Diagnosis)
  • Tufts Health Plan will reimburse providers for treatment according to covered benefits in our plans for those members positively diagnosed with COVID-19.
  • Tufts Health Plan will cover these costs in full without member cost sharing (i.e. no copays, deductible or coinsurance). This applies to all treatment regardless of place of service, including inpatient and skilled nursing facility (SNF) services.
  • 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, used as either a primary diagnosis or a secondary diagnosis appended to a respiratory illness.
  • For members on closed network plans, Tufts Health Plan will pay allowed amounts at in-network providers and with out-of-network providers if a member has trouble accessing such services in-network.
    • In such a case, Tufts Health Plan will hold the member harmless from a financial perspective when using an out-of-network provider.
COVID-19 Treatment (Initially Suspected, But Without Confirmed Positive Diagnosis)
  • Tufts Health Plan will reimburse providers for treatment according to covered benefits in our plans for those without a positive diagnosis of COVID-19.
  • Tufts Health Plan will cover these costs in full without member cost sharing (i.e. no copays, deductible or coinsurance). This applies to all treatment regardless of place of service, including inpatient and SNF services.
    • 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.
  • For members on closed network plans, Tufts Health Plan will pay allowed amounts at in-network providers and with out-of-network providers if a member has trouble accessing such services in-network.
    • In such a case, Tufts Health Plan will hold the member harmless from a financial perspective when using an out-of-network provider.
Telehealth/Telemedicine

The following telehealth/telemedicine policy has been implemented to prevent members from needing to leave their home to receive care. This applies for all diagnoses and not specific to a COVID-19 diagnosis.

  • Tufts Health Plan will compensate in-network providers at 100% of their contracted rate for services rendered in person, as specified in provider agreements. The telehealth reduction will not apply.
  • Out-of-network (OON) providers will be reimbursed using our standard processes for reimbursing OON claims when coverage is allowed (e.g. PPO members whose plan includes OON coverage, and for HMO members when OON services are authorized).
  • All Tufts Health Plan contracting providers, including specialists and urgent care facilities, may provide telemedicine services to members for all medical (well visits/preventive and sick visits), 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 for telehealth services.
  • Tufts Health Plan will waive member cost share for any in-network telehealth service and OON telehealth services when authorized because services are not available in network. This includes both facility and professional services.
  • This will also include 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.
  • 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, this is an additional benefit available to Commercial members.

Billing Guidelines

Commercial Products (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)
  • Providers must submit claims with POS 02  to indicate when telehealth services have been rendered for professional claims.* For facility claims, providers should submit Revenue Code 780 (Telemedicine, general). When appropriate, providers are asked to please submit modifiers.
  • Refer to the Claims Submission and Timely Filing section below for additional billing guidelines.
 
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

* Modifiers are not required for Behavioral Health claims.

Tufts Health Medicare Preferred and Tufts Health Plan SCO
  • Providers must submit claims with POS 02.
  • Refer to the Claims Submission and Timely Filing section below for additional billing guidelines.
Claims Submission and Timely Filing
  • The filing deadline for initial 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 should follow guidelines on this page 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.
Pharmacy
  • Allow a pharmacy claim with submission code 13 (SCC13) to waive the refill limitation for the refill of a maintenance medication prescription.
  • Maintenance medications are defined by the Medispan Indicator for Maintenance Drugs and include specialty pharmaceuticals.
  • Allow this refill to be for up to a 90-day supply.
  • Controlled substances are excluded from this policy.
  • If a vaccine for COVID-19 is developed, Tufts Health Plan will provide 100% coverage. Members will have no cost sharing responsiblity.
Prior Authorization and Notification Flexibility
 
  • 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 will not be required.
    • Notification will be 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 will not be required for inpatient rehab, skilled nursing facilities and home care following an inpatient hospital admission.
    • Notification will be required within 5 days after the date of admission
    • All other post-acute policies remain unchanged.
  • Urgent/emergent inpatient admissions:
    • Tufts Health Plan will offer relaxed admission notification requirements for urgent/emergent inpatient admissions by requiring notification within 5 days after the date of admission. Concurrent and retrospective reviews will be conducted as warranted.
  • Elective non-COVID-19 admissions: Tufts Health Plan will still require inpatient notification.
  • Hospice services:  Prior authorization or notification will not be required.
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.

For behavioral health providers contracted with Commercial (including Tufts Health Freedom Plan) and Tufts Health Public Plans products, refer to the Behavioral Health Prior Authorization and Notification Process During COVID-19 Office Closures.

The above applies to all fully-insured and self-insured groups. Self-insured groups do have the option to opt-out of any of these policies but must do so in writing. 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 .

* If necessary, the date may be extended.