Introduction to Tufts Health Plan Purpose of This Manual

Commercial Provider ManualIntroduction to Tufts Health PlanPurpose of This ManualTufts Health Plan developed this guide to supply our providers and their office staff with details on the products,policies, and procedures of Tufts Health Plan. Tufts Health Plan recommends that providers and their staff read thismanual and reference it as necessary.Overview of Tufts Health PlanTufts Health Plan is a family of companies designed to arrange for comprehensive health care services to itsmembers. Tufts Health Plan encourages appropriate treatment and efficient use of medical services in the provider’soffice. Tufts Health Plan offers eligible employer groups and individual enrollees a range of products and plandesigns that include, but are not limited to:Health Maintenance Organization (HMO)Point of Service (POS)Preferred Provider Organization (PPO)Tufts Health Plan Medicare Complement (TMC) Tufts Medicare Preferred HMO plans 1Refer to Understanding Our Plans for overviews of our products and information that will make it easier for youwhen servicing a Tufts Health Plan member.Structure and Administration of Tufts Health PlanTufts Health Plan’s provider networks consist primarily of “provider units,” composed of individual providersaffiliated with one or more hospitals. The main goal of the provider-hospital relationship is to promote localprovider ownership of the managed-care process.Board of DirectorsThe Board of Directors is responsible for setting the company’s strategic direction, monitoring its course, andapproving the annual business plan.Physicians Advisory CommitteesThese committees are established by the Department of Medical Affairs to address quality improvement andutilization management issues. They provide input for development and implementation of clinical programs.Directory of DepartmentsWhen making calls to Tufts Health Plan, use the following directory to identify the most appropriate department tocall.1. For information about the Tufts Medicare Preferred HMO plans, refer to the Tufts Medicare Preferred HMO Provider Manual.Tufts Health Plan 1tuftshealthplan.com/providers

Introduction to Tufts Health PlanDepartment Contact ResponsibilityClinical ServicesCase ManagementCare Manager1-888-766-9818 • Concurrently reviews Tufts Health Planmembers hospitalized at Tufts Health Planfacilities• Coordinates and authorizes discharge plans,including rehabilitation, Skilled NursingFacility (SNF) or chronic hospitalplacement, home health care, hometherapies, and Durable Medical Equipment(DME)Specialty Care Manager 1-888-766-9818 • Facilitates discharge planningMental Health Department• Provides ongoing coordination of servicesthrough the continuum of illness ofmedically complex cases• Acts as plan liaison for members, families,providers and vendors of ancillary services• Manages medically complex cases• Performs out-of-network hospital reviewsand discharge planning• Manages high-risk obstetrics, pediatrics,neonatology, transplants, HIV/AIDS,disabilities, rehabilitation nursing, andoncology casesMental Health Outpatient ClinicalCoordinator and ServiceRepresentative1-800-208-9565 • Manages requests for outpatient mentalhealth and substance abuse (MH/SA)services• Coordinates members’ access to inpatientMH/SA servicesMental Health Care Manager 1-800-208-9565 • Facilitates discharge planning for membershospitalized at Designated Facilities (DFs)Precertification Department• Monitors quality of care at mental healthDFsPrecertification Clinical Staff 617-972-9409 (fax) • Coordinates any federal mandates• Authorizes utilization management ofcertain outpatient procedures including, butnot limited to, elective surgeries, selectedmedication, and experimental procedures2 Tufts Health Plantuftshealthplan.com/providers

Commercial Provider ManualDepartment Contact ResponsibilityPrecertification Coordinator 1-800-672-1515 • Preregisters inpatient admissions forcommercial members and assigns an initialapproved length of stay per the Thompsontable.Liability and Recovery• Preregisters inpatient services for TuftsMedicare Preferred HMO members.Coordination of Benefits (COB) 617-972-1098 • Investigates and verifies dual healthcoverageMember Services• Determines primary and secondarycoverage• Investigates and verifies workers’compensation claims• Adjusts coordination of benefits, workers’compensation, and Tufts Health PlanMedicare• Complement (TMC) claims• For additional information, refer to ourCOB Payment Policy on our website.Health Maintenance Organization(HMO)/Point of Service (POS)Member Services SpecialistUniformed Services Family HealthPlan (USFHP) Member ServicesSpecialist1-800-462-0224 • For Tufts Health Plan members only• For all products, the member specialist:- Addresses inquiries from membersregarding paid or in-process claims andExplanations of Payment (also known asStatements of Account)- Interprets member benefits- Answers member questions regardinggeneral use of plan- Assists members with choice or change ofprimary care provider (PCP)- Confirms member eligibility- Addresses member problems or complaints1-800-818-8589 • For USFHP members and providersCommonwealth of Massachusetts,GIC Member Services Specialist1-800-870-9488 • For Commonwealth of Massachusetts, GICmembers only3 Tufts Health Plantuftshealthplan.com/providers

Introduction to Tufts Health PlanDepartment Contact ResponsibilityPreferred Provider Organization(PPO) Member Services Specialist1-800-423-8080 • For Tufts Health Plan members onlyRhode Island–Based EmployerGroups Member Services Specialist1-800-682-8059 • For members of Rhode Island basedemployer groupsNetwork Contracting and Performance ManagementContract Manager 1-888-880-8699 ext. 2169 • Negotiates contracts with providerorganization leadershipContract Specialist 1-888-880-8699 ext. 2169 • Ensures contract terms are implemented inappropriate Tufts Health Plan systems• Fosters and maintains provider networkrelationshipAssociate Contract Specialist 1-888-880-8699 ext. 2169 • Processes operational changesNetwork ManagementProvider Information Specialist 1-888-306-6307 • Facilitates change of provider practice orpayment information status• Facilitates provider terminationsProvider Credentialing Specialist 1-888-880-8699 • Processes new credentialing andrecredentialing applications for providersand certain ancillary providers (includingindependent licensed practitioners andorganizational providers, such as acutehospitals, rehabilitation hospitals,freestanding surgical centers, and others)and verifies completeness of theapplication.Provider ServicesProvider Specialist 1-888-884-2404 Providers should call this number for thefollowing issues:• Inquiries regarding paid or in-processclaims• Interpretation of member benefits4 Tufts Health Plantuftshealthplan.com/providers

Commercial Provider ManualDepartment Contact ResponsibilityProvider Education 1-888-306-6307 • Educates providers about products, policiesand procedures, self- service technologysolutions• Offers the following educational programs:• Self-service Training• Webinars• Onsite Meetings• Ad hoc MeetingsEDI Operations 1-888-880-8699 ext. 4042 • Makes inquiries concerning electronicclaims files• Sets up electronic servicesClinical Quality Improvement (CQI) 888-766-9818, ext. 4276. • Works directly with the involved providerto review the clinical event, identifyopportunities for quality improvementLast updated 05/2013. Chapter revision dates may not be reflective of actual policy changes.5 Tufts Health Plantuftshealthplan.com/providers