Electronic Services

E-Solutions for your everyday needs

Tufts Health Plan offers a wide range of electronic solutions, including member eligibility status, benefit information, claim submission, and clinical information.

Electronic self-service tools save time and will help streamline providers' practices, reduce administrative costs, and increase information security.

Authorization

Referral Submission and Inquiry

Providers may submit referrals electronically for members, receive a referral number upon submission, and verify the remaining number of visits using the following:

For Commercial (including Tufts Health Freedom Plan), Tufts Medicare Preferred HMO, Tufts Health Plan SCO and Tufts Health Public Plans Massachusetts products

For Tufts Health RITogether

Inpatient Notification

For Commercial (including Tufts Health Freedom Plan), Tufts Medicare Preferred HMO, Tufts Health Plan SCO and Tufts Health Public Plans Massachusetts products

For Tufts Health RITogether

Behavioral Health Service Requests

Request authorization for initial and continuing visits and check authorization status using Tufts Health Plan's secure Provider portal or by using the Behavioral Health IVR at 800.208.9565.

 

Claims

Claim Options

With electronic data interchange (EDI), providers can submit claims electronically (either directly or through a clearinghouse) and receive electronic remittance from Tufts Health Plan.

Claim Submission

For quicker payment, fewer rejections and ease of processing, providers can send their claims electronically to Tufts Health Plan using the following options:

Direct EDI Claim Submission

For direct submission, a provider's billing system is set up to connect with the claims system at Tufts Health Plan. Direct claim submission also includes support with a Tufts Health Plan EDI analyst for quick resolution of any EDI issues. There are no charges for direct claims submission.

For more information about direct EDI claim submission, call 888.880.8699, ext. 54042 or email questions to edi_operations@tufts-health.com.

Note: Claims submitted without a registered provider’s NPI, dental, and pharmacy claims cannot currently be submitted via EDI.

Clearinghouse Claim Submission

Tufts Health Plan accepts EDI claims from all major clearinghouses. Send one electronic file for all your claims to the clearinghouse. The clearinghouse, in turn, distributes those claims to all of the payers, including Tufts Health Plan. There is usually a fee associated with using a clearinghouse. Click here to access the EDI set-up form.

Before beginning, contact the Tufts Health Plan EDI Operations Department at 888.880.8699, ext. 54042.

Online Claim Submission

Tufts Health Plan now offers online claim submission to its providers through MD On-Line, now part of the ABILITY® Network. This option is available for professional claims only for all Tufts Health Plan products.

Providers who are already registered with MD On-Line may add Tufts Health Plan as a payer. Providers who are not yet registered should call MD On-Line at 888.499.5465 and mention that you are a Tufts Health Plan provider. All questions about registration should be directed to MD On-Line.

Note: Claims that require supporting documentation cannot be submitted electronically and providers should continue to submit these claims on paper.

Claim Status Inquiry

View both pending and processed claims as well as review message codes, payment dates, check numbers and more via the following:

For Commercial (including Tufts Health Freedom Plan), Tufts Medicare Preferred HMO, Tufts Health Plan SCO and Tufts Health Public Plans Massachusetts products

For Tufts Health RITogether

Online Claim Adjustments

Providers may submit and track Commercial claim adjustments online using the Claim Status Inquiry (CSI) tool on Tufts Health Plan's secure Provider portal. The CSI tool allows providers to perform the following functions:

  • Adjust previously submitted claims, including changing provider and payee ID numbers, procedure and diagnosis codes, billed amounts, modifiers and member information.
  • Submit payment disputes by filling out an electronic form that includes the rationale for the request and allows providers to attach electronic documents for paperless submission or send supporting documents by mail.
  • Return funds by selecting either a claim refund via check or a claim to have retracted from future claim payments

Electronic Remittance Advice (ERA)

Whether claims are submitted directly, through a clearinghouse, or online through MD On-Line, Tufts Health Plan offers electronic remittance from PaySpan Health, allowing providers to automatically post payments and denials for all claims.

Clinical Tools

InterQual® Clinical Criteria and SmartSheets™

Tufts Health Plan applies InterQual criteria to certain procedures requiring prior authorization. These criteria are available on Tufts Health Plan's secure Provider portal. By logging in, providers can:

  • Review InterQual criteria for certain procedures or view a Clinical Evidence Summary
  • Access InterQual SmartSheets for submitting authorization requests to Tufts Health Plan

Clinical Quality Management (CQM) Reports

Member Health Management Reports, published monthly on the secure Provider portal, help providers track and monitor member care and manage conditions. These reports show each member's most recent date of service for key screening tests or prescriptions and are benchmarked against HEDIS® performance standards.

Member Inquiry

Eligibility and Benefits

Verify member eligibility status using the following self-service channels:

For Commercial (including Tufts Health Freedom Plan), Tufts Medicare Preferred HMO, Tufts Health Plan SCO and Tufts Health Public Plans Massachusetts products

Tufts Health RITogether

Note: Eligibility may be subject to retroactive reporting of disenrollment.

Electronic Funds Transfer (EFT)

Tufts Health Plan offers Electronic Funds Transfer, Electronic Remittance Advice (ERA) and Explanations of Payment (EOP) to providers through PaySpan® Health.

This solution allows online presentment of remittance and EOPs, and the option to direct electronic payment to a bank via direct deposit instead of payment by traditional paper check. Providers who choose the electronic payment option will no longer receive paper checks and EOPs.

How to Register with PaySpan Health

If you are already registered with PaySpan Health, log into your PaySpan Health account at Payspan Health and add Tufts Health Plan as a payer. If you are not already registered, call PaySpan Health at 877.331.7154 for your unique registration code. Then go to Payspan Health and click the Register Now button.

Enter your registration code, Provider ID Number (PIN) and Tax ID Number (TIN) in the boxes provided. Then click Start Registration to begin the registration process. Have your bank routing and account number found on your check available.

A step-by-step registration guide is available through Payspan Health.