Tufts Medicare Preferred HMO Provider Manual - Tufts Health Plan

Tufts Medicare Preferred HMO Provider ManualIntroductionPurpose of ManualTufts Health Plan developed this manual to provide Tufts Medicare Preferred HMO providers and their office staffwith details on the structure, products, policies and procedures of Tufts Medicare Preferred HMO. Tufts Health Planrequires that providers and their office staff read abide by and reference this manual as necessary.Overview of Tufts Medicare Preferred HMOIn 1982, Congress passed the Tax Equity and Fiscal Responsibility Act (TEFRA), allowing the federal governmentto contract with Managed Care Organizations (MCOs), such as Tufts Associated Health Maintenance Organization,Inc. (“Tufts Health Plan”). Tufts Health Plan entered into a Medicare risk contract with the Centers The program towhich our contract with CMS pertains is referred to as "Medicare Advantage." Tufts Health Plan is a “MedicareAdvantage” organization and its product is known as Tufts Medicare Preferred HMO.CMS pays Tufts Health Plan a per member per month amount to cover the cost of approved services.To implement the various statutes on which the Medicare Advantage Program is based, CMS issues regulations.CMS also publishes various manuals, memoranda and statements necessary to administer the programs. EachMedicare Advantage Organization having a Medicare Advantage contract with CMS must comply with theserequirements. CMS conducts routine regulatory audits to review the MAO’s procedures and to ensure complianceby the MAO as well as Providers under contract to the MAO with federal requirements.Tufts Medicare Preferred HMO members effectively assign their Medicare benefits to Tufts Medicare PreferredHMO. Tufts Health Plan assumes total responsibility for meeting the covered health care needs of the enrolledMedicare beneficiaries. In addition to services covered by Medicare, Tufts Medicare Preferred HMO also providesother specific benefits.Primary Care ProvidersTufts Medicare Preferred HMO members are required to choose a PCP participating in the Tufts Medicare PreferredHMO network. Appropriately authorized medically necessary services are covered at 100% less an applicable costsharingamount.Referrals from the member’s PCP are required for coverage of specialty care services, and members must beinformed of their potential liability for payment of unauthorized services. Preregistration is required for allambulatory surgical day care services and for inpatient admissions.Department DirectoryThe following departments manage Tufts Medicare Preferred HMO provider information.• Network Management and Contracting• Precertification• Tufts Health Plan Medicare Preferred Provider Relations• Provider Communications and EducationWhen contacting Tufts Health Plan or Tufts Health Plan Medicare Preferred, use the Department Directory toidentify the most appropriate department, phone and fax contact numbers, and individual role responsibilities.Tufts Health Plan Medicare Preferred 1tuftshealthplan.com/providers

Tufts Medicare Preferred HMO Provider ManualDepartment Contact ResponsibilityNetwork Management and ContractingNetwork Contracting andPerformance Management(NCPM)Allied Health Services.888-880-8699 x2169 • Contract Manager617-972-9411− Negotiates and executes contracts for TuftsMedicare Preferred HMO medical groups,providers and hospitals.• Associate Contract Specialist− Processes operational changes• Contract Specialist− Monitors Tufts Medicare Preferred HMOmedical group and hospital performance.− Fosters and maintains medical grouprelationships− Ensures contracts are implemented in theappropriate Tufts Health Plan systemsAllied Health Contract Administrator• Negotiates and administers contracts for allancillary services, skilled nursing facilities,inpatient rehabilitation hospitals, and home careservices• Evaluates prospective ancillary providers andassesses need for additions and changes to thecontracting provider network• Monitors contract compliance and performsutilization review of contracts• Keeps abreast of federal and state regulatorylicensing and credentialing information for allancillary services, skilled nursing facilities,inpatient rehabilitation hospitals, and home careservices• Recommends necessary revisions to contracts• Responds to questions regarding ancillary providersand available servicesDepartment Contact ResponsibilityProvider Credentialing1-888-306-6307Provider Credentialing SpecialistMaintains practitioner credentialing /recredentialing process.Provider Information1-888-306-6307Provider Information Specialist• Facilitates change of provider application• Facilitates change of provider practice or paymentinformation2 Tufts Health Plan Medicare Preferredtuftshealthplan.com/providers

Tufts Medicare Preferred HMO Provider ManualPrecertificationPrecertificationCoordinatorPrecertification ClinicalStaff1-800-672-15151-800-843-3553 (fax)617-972-9409 (fax)Preregisters inpatient admissions and surgical day careservices• Reviews requests for formulary or pharmacy tieringexceptions for Tufts Medicare Preferred HMOMembersCase Management 1-888-766-9818• Concurrently reviews Tufts Medicare PreferredHMO members hospitalized at an in-plan facility.• Coordinates discharge planning, includingrehabilitation, skilled nursing facility, or chronichospital placement, home health care, hometherapies, and durable medical equipmentTufts Health Plan Medicare Preferred Provider RelationsProvider Specialist 1-800-279-9022• Addresses inquiries regarding covered benefits,claims, and Statements of Account• Confirms member eligibility• Answers general and specific provider questionsProvider Communications and EducationProvider EducationSpecialist1-888-306-6307 • Educates providers about products, policies andprocedures, self- service technology solutions• Offers the following educational programs:• Self-service training• Webinars• Onsite meetings• Ad hoc meetingsLast updated 08/2012. Chapter revision dates may not be reflective of actual policy changes.3 Tufts Health Plan Medicare Preferredtuftshealthplan.com/providers