Massachusetts Association of Patient Account Management (MAPAM) All Payers Meeting

May 17, 2018

Division and Product Organization To optimize use of our online resources, you must identify and select the Tufts Health Plan division in which your patient is enrolled: • Commercial • Medicare • Tufts Health Plan Senior Care Options (SCO) • Tufts Health Public Plans

Refer to the Products Overview and Member ID Card Guide for assistance in determining the member’s plan and the division under which the plan falls.

Selecting a Division

To find the information that you need, identify which division of

Tufts Health Plan your patient’s plan is listed under.

Tufts Health Plan Commercial plans, Tufts Medicare Preferred

HMO, Tufts Health Plan SCO and Tufts Health Public Plans

require separate provider agreements.

Accept patients with plans that are listed in the divisions with

which you hold provider agreements.

Always verify member eligibility.

• Check the member’s ID card to determine the member’s plan.

• Use the secure Provider website to verify the member’s plan.

Navigating Tufts Health Plan’s Website tuftshealthplan.com/provider

Tufts Health Plan’s Provider website has two distinct sections:

Public Provider website • Medical necessity guidelines • Payment policies • Pharmacy programs • Provider manuals • Training and education

Secure Provider website (registration required)

1. Tufts Health Provider Connect (Tufts Health Public Plans only)

2. Tufts Health Plan Provider Portal (Commercial and Senior Products)

• Claims status inquiry

• Eligibility and benefits

• Referral inquiry and submission

• Inpatient notification request submission

• Online claim adjustments (now available for Senior Products)

Secure Provider Website Login - Select a Division

Recommended Browsers

Tufts Health Plan recommends using the latest versions of one

of the following Internet browsers for the public and secure

Provider websites:

Mozilla Firefox

Google Chrome

Internet Explorer is not optimal for working on the public and secure Provider websites.

NEW Secure Provider Website for Commercial and Senior Products

Claims Status Inquiry

Claims Status Inquiry - Free Form Search You can search with any information related to the claims that

you are looking for. For example, if you are looking for a claim from July. Just type “July” in to the search box, and claims associated with the month of July will be returned.

You can search for multiple pieces of information at once. For example, you can enter many claim numbers returning multiple results. You can also enter multiple pieces of information related to a single claim in order to refine search results.

When searching for multiple pieces of information at once, simply put a comma and/or space in between your search items.

Claims Status Inquiry - Free Form Search (continued)

Here are some other pieces of information you may

use to refine your search:

Service Date Receipt Date Pay Date Total Paid Total Billed Check Number Patient Account Number Member ID Member First Name, Last Name and/or Date of Birth Status Code and/or Category Description Payee NPI and/or Name Provider NPI and/or Name Procedure Code and/or Description

Online Claim Adjustments

Provider Payment Dispute Overview

Providers have the right to file a payment dispute if they disagree with a decision regarding the denial or compensation of a claim.

The Online Claim Adjustment Tool on the secure Provider website is the primary means of submitting Commercial and Senior Products claim adjustment requests and payment disputes.

When submitting a payment dispute by mail, the Request for Claim Review Form, along with any supporting documentation, is required. The form can be found in the Forms section of the Resource Center at tuftshealthplan.com/provider.

A separate dispute form must be submitted for each claim adjustment.

All incomplete submissions will be returned.

For complete information, refer to the Provider Payment Dispute Policy found in the Payment Policy section of the Resource Center on the public Provider website.

Tufts Health Freedom Plan and Tufts Health Plan Commercial Plans

Commercial providers may see Tufts Health Freedom Plan members. Tufts Health Freedom Plan members will have a Tufts Health Freedom Plan member ID card, and Tufts Health Plan Commercial members will have a Tufts Health Plan member ID card.

Reminder: Use Tufts Health Plan's secure Provider website to verify member eligibility, determine the member's plan type and access benefit information: tuftshealthplan.com/provider.

Tufts Medicare Preferred HMO plans and the Tufts Health Plan Senior Care Options (SCO) Plan earned a 5 out of 5 star rating from Medicare for the third year in a row!

This rating is a reflection of how well Tufts Health Plan supports its members and their health needs.

Tufts Health Public Plans

Tufts Health Public Plans provide access to high-quality health care for Massachusetts and Rhode Island residents with low to moderate incomes.

Plan offerings include: Tufts Health Direct – Health Connector (A focused network plan for

individuals and small groups)

Tufts Health Together – Includes Mass Health Plan, as well as the following Accountable Care Partnership Plans (Effective 3/1/18):

Tufts Health Together with Atrius Health

Tufts Health Together with BIDCO

Tufts Health Together with Boston Children’s ACO

Tufts Health Together with CHA

Tufts Health RITogether – A RI Medicaid Plan (serving RIte Care and Rhody Health Partners members)

Tufts Health Unify – OneCare Plan (Medicare-Medicaid plan)

Blue stripe indicates a Tufts Health Public Plans product.

Tufts Health Public Plans Member ID Cards

Plan type

Each ACO plan includes unique features and special programs.

Tufts Health Together ACO Member ID Cards

Tufts Health RITogether

Tufts Health RITogether, our Rhode Island Medicaid plan, provides health insurance to eligible members of the state of Rhode Island.

A separate provider agreement is needed for participation in the Tufts Health RITogether provider network.

Tufts Health Provider Connect Tufts Health Provider Connect offers secure online self-service tools for

Tufts Health Public Plans products.

Tufts Health Public Plans products include Tufts Health Direct, Tufts Health RITogether, Tufts Health Together and Tufts Health Unify.

Tufts Health Provider Connect User Guide

MedHOK Provider Portal User Guide Inpatient notifications and prior authorization requests for outpatient

services, for Tufts Health Direct and Tufts Health Together plan members, should be entered in the MedHOK online tool that is accessed through Tufts Health Provider Connect.

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Register to Receive Provider Update by Email

The registration form can be accessed on the public Provider website at tuftshealthplan.com/provider. Click "Register Your Email" below to complete and submit the short registration form.

Note: This email address will be used only for required notifications and other pertinent business communications. It will not change or grant login credentials to the secure Provider website.

View changes that apply to Commercial products.

Provider Update - tuftshealthplan.com/provider/news

Provider Education and Training - Provider Resource Guides tuftshealthplan.com/provider/training/guides-and-resources

Provider Education and Training - Office Manager Meetings

tuftshealthplan.com/provider/training/office-managers-meetings

Provider Education and Training - Webinars tuftshealthplan.com/provider/training/webinars

Thank you!