Tufts Health Public Plans. Provider Manual

Transcription

1 2017 Tufts Health Public Plans Provider Manual

2 Can t find information you need in this manual? Be sure you ve selected the correct provider manual, or follow one of the links below: Commercial Provider Manual Tufts Medicare Preferred HMO Provider Manual Tufts Health Plan Senior Care Options Provider Manual 5343B Tufts Health Public Plans Provider Manual INTRO

3 CHAPTER 1: OVERVIEW The Tufts Health Public Plans Provider Manual We are committed to partnering with you to provide high-quality care to your Tufts Health Public Plans patients. Tufts Health Public Plans is licensed as a health maintenance organization in Massachusetts, but does business under the name Tufts Health Plan. Tufts Health Public Plans includes the following products: Tufts Health Direct, Tufts Health Together, and Tufts Health Unify. The 2017 Provider Manual is one way that we help you find information to support your patients health needs quickly and effectively. The Provider Manual outlines Tufts Health Public Plans policies, as well as state and federal regulatory requirements that may impact you as a participating Tufts Health Public Plans provider.* Each chapter begins with a detailed outline that can link you directly to the information that you are looking for. The Provider Manual also includes links to forms and other documents available online that you may need. The Provider Manual serves as an amendment to the provider contract between you or your organization and Tufts Health Plan. Additionally, our quarterly Provider Update newsletter serves to amend our Provider Manual by featuring Tufts Health Public Plans news and other important health care information. You can read Provider Update at tuftshealthplan.com/provider and sign up to receive our newsletter via . Our website also includes updated information, such as: Forms Medical and behavioral health benefit summary grids Payment policies Pharmacy medical necessity guidelines Clinical practice guidelines About Tufts Health Public Plans Tufts Health Public Plans provides access to high-quality health care for more than 240,000 Massachusetts residents with low and moderate incomes. We began as a nonprofit nearly 20 years ago to serve diverse communities and facilitate care coordination to help support the health and wellness of our members. Our approach includes working closely with our providers, listening carefully to our members, and being involved in the neighborhoods we serve. Our experience in coordinated care gives us the background required to help providers navigate this new health care era. We have more than 20,000 primary care providers (PCPs), specialists, hospitals, and community organizations in our network statewide. And we support our providers with a fully integrated in-house care management team that includes medical, behavioral health, social care, and pharmacy professionals who work with you to coordinate member care. We offer several plans to serve diverse member needs including MassHealth plans, a Medicare-Medicaid plan, and new qualified health plans (QHPs) for individuals and small groups. Recognition for Tufts Health Public Plans includes the National Committee for Quality Assurance s (NCQA) Excellent Health Plan Accreditation (NCQA s highest accreditation rating) for our Tufts Health Together plan. During the rankings, we were rated 4.5 out of 5 among health insurance plans. We have also ranked No. 1 among the top 10 Medicaid health plans nationally in 2014, and third in the nation since 2012, according to NCQA s Health Insurance Plan Rankings-Medicaid. Tufts Health Plan is a nonprofit organization nationally recognized for its commitment to providing innovative, high-quality health care coverage to over one million members. For more information about Tufts Health Public Plans, call us at * Providers include hospitals, organizational providers/practitioners, and/or licensed individuals who provide medical or behavioral health services 5343B Tufts Health Public Plans Provider Manual CHAPTER 1: OVERVIEW

4 CHAPTER 2: DOING BUSINESS WITH US We want to make it as easy as possible for you to work with us as you provide care to your Tufts Health Public Plans patients. Refer to this chapter for information about your responsibilities as a Tufts Health Public Plans provider: Your clinical responsibilities Your administrative responsibilities Our fraud and abuse policy Please see Chapter 9 for specific provider responsibilities regarding Tufts Health Unify. Your clinical responsibilities We support your commitment to providing the best care for your Tufts Health Public Plans patients. Please note the following clinical care responsibilities. ALL TUFTS HEALTH PUBLIC PLANS PROVIDERS MUST: Make covered health services available to all Tufts Health Public Plans members Accept and treat Tufts Health Public Plans patients in an identical manner to all other patients in your practice Participate in discharge planning and follow-up Respond to your patients linguistic, cultural, and other unique needs Help your non-english-speaking patients get interpreter services if necessary (patients can call us at for interpretation help) Provide advance directive information according to regulatory requirements as detailed in Chapter 7 Provide or coordinate all age-specific Early Periodic Screening, Diagnosis, and Treatment (EPSDT) services for your Tufts Health Together (MassHealth) patients younger than 21 during all well-child visits, according to MassHealth requirements. See our EPSDT resources to learn more about EPSDT screening tools and reimbursement. Comply with medical record standards as detailed in Chapter 3 Provide treatment consistent with professional standards Have in place systems for accurately documenting Member information Clinical information Clinical assessments Treatment plans Treatment or services provided and outcomes Contacts with a patient s family, guardian, or partner Tufts Health Public Plans Provider Manual CHAPTER 2: DOING BUSINESS WITH US

5 Discharge plans Patients consent for their medical and behavioral health providers to exchange information with each other and with us Notify a patient s primary care provider (PCP) about any services and/or treatment you provide if you are not the patient s PCP Notify our medical management team as soon as possible of a Tufts Health Public Plans patient s pregnancy using the Prenatal Registration Form Cooperate with our quality improvement activities, including state/federal regulatory, National Committee for Quality Assurance (NCQA), and Healthcare Effectiveness Data and Information Set (HEDIS) data requirements Share information with patients about their rights and responsibilities as detailed in Chapter 7. Additionally, see our Suggested Provider Statement of Patient/Client Rights and Responsibilities Form. Notify Tufts Health Public Plans when there is a need to disenroll a Tufts Health Public Plans member from a provider panel. In accordance with disenrolling a patient from a provider s care, policy notification must be provided to Tufts Health Public Plans before providing 30 days notice to the member in writing. Complete an Americans with Disabilities Act (ADA) accessibility survey Please note: As stated in your provider agreement, you cannot charge a Tufts Health Public Plans patient any fee for cancelling or missing an appointment with you. If your patient misses an appointment because of transportation or any other nonmedical need, our social care managers can help. You can call our social care management team at For more information about social care management, please see Chapter 4A. Also, you cannot charge your Tufts Health Public Plans patients for any service that is not medically necessary or not a covered service if you did not explain they would have to pay for the service or explain that other services may meet their needs. You will need to document that you have explained to the patients their financial liability. THE PCP S RESPONSIBILITIES Tufts Health Public Plans members must choose a PCP from whom to get regular services. As a PCP in our network, you must: Offer coverage 24 hours a day, seven days a week, as well as back-up, on-call, after-hours, short-term, and long-term leave-of-absence coverage Offer the following appointment availability: Urgent care (services that are not emergency or routine) within 48 hours of a request Nonurgent symptomatic care (such as for recurrent headaches or fatigue) within 10 calendar days of a request (within 48 hours for Tufts Health Unify members) Nonsymptomatic care within 45 calendar days of a request, unless an appointment is required more quickly to assure the provision of screenings in accordance with the schedule established by the EPSDT Periodicity Schedule (within 30 days for Tufts Health Unify members) Initial prenatal appointments for newly identified pregnancies within 21 calendar days of request Family-planning appointments within 14 calendar days of a request Tufts Health Public Plans Provider Manual CHAPTER 2: DOING BUSINESS WITH US

6 Department of Children and Families (DCF) initial screening for patients in DCF care within seven calendar days of a request, and comprehensive medical screening within 30 calendar days of a request Refer patients to in-network specialists if needed Use our Find a Doctor, Hospital, or Pharmacy tool to find in-network providers See our Specialty Services Referral Requirement Payment Policy for more information Discuss all treatment options with your Tufts Health Public Plans patients, regardless of cost or benefit coverage Allow your patients to exercise their rights without having to worry about adversely affecting their treatment Encourage your patients to let you share information with their behavioral health provider, if they have one, and with us Require your patients to complete the Primary Care Provider (PCP) Selection/Change Form as needed to assign them to your practice Verify before seeing your patients that they are in your practice s panel through Tufts Health Member Connect, NEHEN, or NEHENNet, or Committee on Operating Rules for Information Exchange (CORE) web service, or by calling us at For more information, see our Primary Care Services Payment Policy. Providers who can serve as PCPs The following types of providers can serve as a member s PCP: Providers with internal medicine, pediatrics, adolescent medicine, or family practice specialties Providers credentialed in more than one specialty area as described in the previous bullet, and as detailed in our Primary Care Services Payment Policy and credentialing procedures in Chapter 6 Credentialed nurse practitioners whom we recognize as fully participating PCPs as detailed in our Nurse Practitioner as Primary Care Provider Payment Policy Credentialed physician assistants whom we recognize as fully participating PCPs as detailed in our Primary Care Services Payment Policy and credentialing procedures in Chapter 6 OB/GYNs who serve as PCPs for women and who maintain member panels THE SPECIALIST S RESPONSIBILITIES Along with complying with our overall provider requirements, in-network specialists must: Offer the following appointment availability: Urgent care (services that are not emergency or routine) within 48 hours of a request Nonurgent symptomatic care within 30 calendar days of a request (within 48 hours for Tufts Health Unify members) Nonsymptomatic care within 60 calendar days of a request (within 30 calendar days for Tufts Health Unify members) Initial prenatal appointments for pregnancies within 21 calendar days of request Family-planning appointments within 14 calendar days of a request Have an answering service available 24 hours a day, seven days a week, for emergency care Tufts Health Public Plans Provider Manual CHAPTER 2: DOING BUSINESS WITH US

7 THE BEHAVIORAL HEALTH PROVIDER S RESPONSIBILITIES Along with complying with our overall provider requirements, in-network behavioral health (BH) service providers must: Offer the following appointment availability: Urgent care (services that are not emergency or routine) within 48 hours of a request Routine behavioral health services intake within 10 working days of a request Emergency Services Programs (ESPs) immediately, 24 hours a day, seven days a week Non-24-hour diversionary services within two calendar days of discharge Medication management services within 14 calendar days of discharge Post-hospital-intake services within 10 working days Other outpatient services within seven calendar days of discharge Coordinate with state agencies as detailed in Chapter 4B COORDINATE BEHAVIORAL HEALTH SERVICES We can help you coordinate behavioral health (BH) services for your patients who need them. Call us at We offer clinical access, triage, service authorization, and utilization review. Request prior authorization and submit notifications for services by contacting us. See Chapter 4B for a particular service s criteria and procedure requirements. Encourage your Tufts Health Public Plans patients to sign these forms, and then fax them to us at : Consent to Release Information Form allows Tufts Health Plan to release information about your patients to family members, state agencies, or others. Submit this form with the Combined MCE (Managed Care Entity) Behavioral Health Provider/Primary Care Provider Communication Form) below. Combined MCE Behavioral Health Provider/Primary Care Provider Communication Form allows BH providers and PCPs to share information with each other. Attach to the Consent to Release Information Form, above. For more information about BH services, please see Chapter 4B. Your administrative responsibilities We want to make working with us easy and convenient for you. Please appropriately manage the following key activities so we can support you in providing the best care for your Tufts Health Public Plans patients. Tufts Health Public Plans Provider Manual CHAPTER 2: DOING BUSINESS WITH US

8 UPDATE YOUR INFORMATION It is critical that we have your current and correct provider information, including your address, phone number, hours of operation, panel status, specialties, and language-fluency capabilities. Please notify us of any changes as soon as possible via the Medical or Behavioral Health Provider Information Form. it to us at or fax it to us at You can also call us at MEET REGULATORY REQUIREMENTS We require you to comply with all applicable regulatory requirements, including: Adhering to the Health Insurance Portability and Accountability Act (HIPAA) Screening employees, both upon hiring and on an ongoing monthly basis, to verify that the government has not prohibited them from providing services to our members. Use the U.S. Department of Health and Human Services, Office of the Inspector General s List of Excluded Entities to screen your employees. For more information, please see Chapter 7. GET CREDENTIALED AND RECREDENTIALED Credentialing is our formal process of adding providers to our network and ensuring these providers are and remain qualified to give our members quality care consistent with recognized managed care organization industry standards. We credential professionally competent providers who consistently meet our qualifications, standards, and requirements. For more information about credentialing, please see Chapter 6. HAVE YOUR NATIONAL PROVIDER IDENTIFIER (NPI) AND TAX ID NUMBER Please have your National Provider Identifier (NPI), if applicable, and tax ID number available when you contact us. HIPAA guidelines require that we verify a provider s identity before releasing any member information. Additionally, as HIPAA mandates, you need to include your NPI on all claims you submit, if applicable. Not having your required documentation may affect our ability to process your payment. Tufts Health Public Plans Provider Manual CHAPTER 2: DOING BUSINESS WITH US

9 VERIFY A PATIENT S TUFTS HEALTH PUBLIC PLANS ELIGIBILITY Check patient eligibility on the date of service You must verify a Tufts Health Public Plans patient s eligibility the day you render service. You can verify patient eligibility: For all Tufts Health Public Plans patients in a number of ways, using Tufts Health Provider Connect. For technical information related to verifying eligibility through Tufts Health Provider Connect, please see Chapter 8. New England Healthcare Exchange Network (NEHEN) or NEHENNet Committee on Operating Rules for Information Exchange (CORE) web service Our Interactive Voice Response (IVR) system by calling us at For Tufts Health Together patients only by using MassHealth s Recipient Eligibility Verification System (REVS) online or at MassHealth s 24/7 automated line at If you do not have your patient s member ID, you can use your patient s name, gender, and date of birth when checking eligibility. Please print out and retain the eligibility confirmation. Request to see your patients Tufts Health Public Plans member ID cards We send all of Tufts Health Public Plans patients an individual Tufts Health Public Plans member ID card. Patients must carry and present a Tufts Health Public Plans member ID card whenever they seek health care or pharmacy services. By checking your patients ID cards, you can verify their identification numbers. If your patients lose or damage their ID cards, or change their name or address, they can request a new card by using Tufts Health Provider Connect, our online self-service tool, or by calling us at GET REFERRALS FOR PATIENTS WHO NEED THEM Tufts Health Public Plans patients who have PCPs in certain provider networks require referrals for specialty services. You can check which patients require a referral and the status of referrals when you check eligibility with Tufts Health Provider Connect. You can also check a patient s member ID card or call us at to find out if your patient requires a referral. We allow PCPs to authorize standing referrals (for more than one visit or for a length of time) for specialty services when appropriate. For more information, see our Specialty Services Referral Requirement Payment Policy. CHECK FOR THIRD-PARTY LIABILITY Before sending us a claim, you must identify and obtain payment from any other liable parties, including other insurance companies. Please see Chapter 5 for more information. Tufts Health Public Plans Provider Manual CHAPTER 2: DOING BUSINESS WITH US

10 REFER PATIENTS FOR INTEGRATED CARE MANAGEMENT SERVICES Our integrated care management team helps your Tufts Health Public Plans patients who need specialized care get services for complex clinical needs and overcome nonmedical barriers to health care. We can help your patients by arranging for transportation to and from appointments, accessing community resources, and obtaining basic necessities (e.g., food, housing). Integrated care management services do not require an authorization. Our clinicians assess each request individually. Call us at to connect with our integrated care management team. For more information about integrated care management, please see Chapter 4A. REFER PATIENTS FOR HEALTH COACHING Your Tufts Health Public Plans patients who need additional health support can get it for free by phone any time they need it with our 24/7 NurseLine, 888-MY-RN-LINE ( ). For more information about health coaching, please see Chapter 4A. FOLLOW CLAIMS AND PRIOR AUTHORIZATION PROCEDURES For details about prior authorizations and utilization management, please see Chapter 4D. For details about claims, please see Chapter 5. Tufts Health Public Plans Provider Manual CHAPTER 2: DOING BUSINESS WITH US

11 Our fraud and abuse policy Please help us reduce health care fraud and abuse and protect MassHealth, the Health Connector, and other state and federal programs for those who need them. Fraud is intentional deception or misrepresentation a person or corporation makes, knowing the deception could result in some unauthorized benefit under state or federal laws or programs to the person or corporation, or some other person. It also includes any act that constitutes fraud under applicable state or federal health care fraud laws. Provider (or contracted managed care organization) abuse includes practices inconsistent with sound fiscal, business, or medical practices that result in unnecessary cost to the state. Member abuse includes actions or inactions that result in unnecessary cost to the state. Examples of fraud and abuse include: Members lending their ID cards to someone else to obtain health care or pharmacy services Members providing false information when applying for programs or services Providers performing unnecessary tests or procedures Providers billing for services or supplies they did not deliver, or reporting incorrect diagnoses or procedures to maximize payment Providers charging separately for services that were part of a single procedure Providers prescribing medications improperly Providers accepting or giving either money or services for member referrals Please note that your patients may receive a letter from us to verify that they received the services for which you billed. If you have questions, suspicions, concerns, or would like to report potential fraud and abuse involving a Tufts Health Public Plans member or provider, please call us at or us at fraudandabuse@tufts-health.com. You do not need to identify yourself. You may also call our confidential compliance hotline at , or send an anonymous letter to us at: Tufts Health Plan Attn: Fraud and Abuse 705 Mount Auburn Street Watertown, MA B Tufts Health Public Plans Provider Manual CHAPTER 2: DOING BUSINESS WITH US

12 CHAPTER 3: QUALITY We are committed to working with you to help continuously improve the quality of health care you provide to your Tufts Health Plan patients. Refer to this chapter for information about: Our Quality Management and Improvement Program (QMIP) Quality Improvement (QI) activities National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medical and treatment record reviews Confidentiality of member medical records Reporting Clinical practice guidelines Pay for performance Patient safety Delegation We monitor the following key areas to continually improve the access to, and quality and frequency of, the medical and behavioral health care and services that our members receive: Preventive health services such as well-child visits Acute and chronic care Care provided to members with specific diagnoses (e.g., diabetes, asthma, depression, and attention deficit/hyperactivity disorder) Continuity and coordination of behavioral health services and medical care Services and medication underuse and overuse Patient safety and risk management Patient complaints, appeals, and grievances Member and provider satisfaction Medical record documentation Tufts Health Public Plans Provider Manual CHAPTER 3: QUALITY

13 Our Quality Management and Improvement Program (QMIP) Our Quality Management and Improvement Program (QMIP) exists to ensure your Tufts Health Public Plans patients receive high-quality medical and behavioral health care, access to primary and specialty care, continuity and coordination of care across settings, and culturally competent care. With our QMIP, we measure and track key aspects of care and services, use data-driven monitoring to identify improvement opportunities, implement interventions, and analyze data to determine overall intervention effectiveness in improving clinical care. We strive for continuous improvement and innovation in meeting our members health care needs and work with you to ensure they receive high-quality health care in the right place, at the right time, and in the most effective and efficient manner possible. We develop QMIP objectives each year as outlined in our annual QMIP Description, which documents the scope, structure, and function of the QMIP. We also evaluate our success in achieving our annual QMIP goals each year and document the results in our Quality Management and Improvement and Utilization Management Program Evaluation. QUALITY IMPROVEMENT (QI) ACTIVITIES Providers cooperate with Tufts Health Public Plans QI activities to: Improve the quality of care, services, and the member experience, including the collection and evaluation of data and participation in Tufts Health Public Plans QI programs Allow the organization to collect and use performance measurement data Assist the organization in improving clinical and service measures NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) As an NCQA-accredited Medicaid and Exchange health plan, we adhere to NCQA standards and guidelines to measure, analyze, and improve the health care services our members receive. HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET (HEDIS) HEDIS measures are industry-standard indicators of the quality of care your Tufts Health Public Plans patients receive. We generate HEDIS administrative rates on a monthly basis and use the data to monitor trends and identify opportunities to improve overall quality. We monitor interim and annual rates against national and regional HEDIS benchmarks. Although we collect data for all HEDIS measures annually, we typically focus improvement efforts on measures related to preventive care and management of chronic conditions such as diabetes and asthma. We focus on measures most directly tied to the way our members get care. By responding to our HEDIS-related requests, you help us measure the care our members receive so we can improve the services we deliver. HEDIS data are incorporated into semiannual provider performance reports, which are tools intended to drive quality improvement. We share performance reports with provider practices to make sure you have the information you need to give your Tufts Health Public Plans patients the best care possible. These reports include performance on several key HEDIS measures. If you have questions about our provider performance reports, call us at Tufts Health Public Plans Provider Manual CHAPTER 3: QUALITY

14 THE CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS (CAHPS) The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a set of standardized surveys that measure patients satisfaction with their care experience. These surveys cover topics such as a provider s communication skills and service accessibility. We use CAHPS survey responses annually to help develop action plans, performance goals, and improvement strategies. We review improvement strategies annually. MEDICAL AND TREATMENT RECORD REVIEWS We use medical record documentation standards and behavioral health (BH) treatment record standards to assess your record-keeping practices prior to accepting you into our network, and we will audit these practices as part of ongoing network management. Chapter 4B describes additional standards we apply for BH treatment records. Chart audits may be part of the HEDIS chart review process, which is part of our contractual obligations with regulatory agencies to monitor appropriateness of care and the quality of record-keeping. Site visits initiated in response to complaints or quality concerns always include medical record-keeping practice reviews. If necessary, we will set up a time with you in advance to review the medical records. If you have any questions about our medical record review process, call us at CONFIDENTIALITY OF MEMBER MEDICAL RECORDS Federal law permits and Tufts Health Public Plans requires that providers comply with all applicable laws relating to the confidentiality of member medical records, including but not limited to the privacy regulations of the Health Insurance Portability and Accountability Act (HIPAA). Providers must: Maintain medical records in a space staffed by office personnel Maintain medical records in a locked office and/or password-protect electronic medical records when staff is not present Prohibit unauthorized review and/or removal of medical records Maintain and adhere to policies and procedures regarding patient confidentiality Tufts Health Public Plans monitors providers compliance with its confidentiality policies through clinical quality reviews and audits. Tufts Health Public Plans requires providers, upon request, to provide member medical information and medical records for the following purposes: Administering Tufts Health Public Plans health benefit plans, such as claims payment, coordination of benefits, subrogation, enrollment eligibility verification, reinsurance, and audit activities Managing care, such as utilization management and QI activities Carrying out member satisfaction procedures described in our Member Handbook Participating in reporting on quality and utilization indicators, such as HEDIS Complying with the law Tufts Health Public Plans Provider Manual CHAPTER 3: QUALITY

15 Providers are responsible for obtaining any member consents or releases that are necessary to comply with state and federal law. Note: A member s consent/authorization to release medical records to Tufts Health Public Plans for the purpose of an appeal is not necessary. REPORTING Twice a year we will send you a report listing the names of your Tufts Health Public Plans patients with asthma and/or diabetes who are overdue for important health-related screenings or who may benefit from a discussion about medication usage. We also do the same for women s health-related screenings, such as screenings for breast cancer, cervical cancer, and chlamydia. For more information about our asthma and diabetes disease management programs or our women s health management programs, please see Chapter 4A. For more information about our asthma and diabetes reports, please call us at When applicable, we also provide performance reporting mechanisms for certain PCPs to review their clinical performance. Tufts Health Plan is contractually obligated to provide information to state and federal governments about the quality of care that our members receive. Occasionally, we ask providers for information that is not available in claims or administrative data for the two government programs we describe next. Quality Improvement Program (QIP) MassHealth evaluates our performance annually on a set of predetermined quality measures and evaluates the initiatives that we implement to improve performance. External Quality Review Organization (EQRO) The Centers for Medicare and Medicaid Services (CMS) and MassHealth arrange for objective, external third parties to evaluate the quality of the managed care plans with which they contract. These third parties evaluate the design, implementation, and performance of specific quality performance improvement programs, as well as our HEDIS program and information systems capabilities. Clinical practice guidelines Our medical, preventive, and behavioral health clinical practice guidelines help ensure quality preventive care and care management. We adopt and/or endorse evidence-based, disease-specific clinical practice guidelines that are either developed by credible medical sources and/or agencies or through regional collaboratives. We periodically update our clinical practice guidelines to include new information about treatments, medications, and technology that reflects best practices. We review our clinical practice guidelines at least every two years, or whenever we learn about new medical evidence, to ensure consistency with accepted practice standards. We also make updated information available to you in a variety of ways, including through our website and our quarterly Provider Update newsletter. Tufts Health Public Plans Provider Manual CHAPTER 3: QUALITY

16 Pay for performance At times, we may offer providers extra reimbursement to improve clinical processes to ensure members get the services they need. We also offer members a variety of rewards for successfully completing key health care activities. For more information about specific programs, see Chapter 4A or call us at We offer you extra reimbursements for the following activities: Pregnancy notification please see Chapter 4A Early Periodic Screening, Diagnosis, and Testing (EPSDT) completion please see Chapter 2 Child and Adolescent Needs and Strengths (CANS) assessments please see Chapter 4B Patient safety We address patient safety by: Facilitating the identification of children with serious emotional disturbances (SED) and monitoring the delivery of behavioral health services to them Distributing information to members pertaining to optimal clinical practices, enhancing their ability to monitor the safety of their own care Monitoring adverse and unanticipated events resulting in death or serious physical or psychological injury occurring in inpatient and residential settings, and identifying trends that could indicate unsafe environments or practices in these contracted institutions Monitoring provider preventable conditions (PPCs) and serious reportable events (SREs). For the full list of PPCs and SREs, please refer to our payment policies or the Massachusetts Executive Office of Health and Human Services June 2012 Transmittal Letter ALL-195. Providers are required to inform Tufts Health Public Plans of SREs and PPCs that occur when serving our members. Monitoring provider medical record legibility and implementing follow-up for substandard documentation practices Monitoring new clinical sites for safety practices Monitoring and managing controlled substances overuse through our controlled substances management program Working with our pharmacy benefit manager to stop a pharmacy from dispensing medications that are inappropriate in terms of drug interaction, drug dosage, ingredient duplication, age precaution, pregnancy precaution, gender conflict, and therapeutic duplication, if the drug on the claim may interact with other drugs in a member s claims history Delegation We delegate selected aspects of our utilization management, pharmacy, disease management, and credentialing programs to approved partners. We review our delegates programs prior to delegation, and at least annually thereafter. Please let us know if you have any questions or concerns about our partners. 5343B Tufts Health Public Plans Provider Manual CHAPTER 3: QUALITY

17 CHAPTER 4A: CARE MANAGEMENT Tufts Health Public Plans care management services include everything you and your patients need, all in one place, to support better health outcomes. Refer to this chapter for information about: Integrated care management Complex care management Behavioral health intensive clinical management (ICM) Social care management Clinical community outreach Transitions of care Disease management Asthma Diabetes Health and wellness support Health coaching Health Library Wellness services Maternal and child health program Prenatal registration Free services and EXTRAS Notification of birth Integrated care management Our integrated care management program offers a multidisciplinary approach to providing care, employing medical, behavioral health, and social care managers working as a team under a single clinical leader. This approach allows the team to evaluate member needs holistically and work with members to develop the most appropriate care plan. Based on members most critical needs, we designate a team leader to work with each member and the rest of the team to co-manage the member s needs through our integrated approach. Additionally, this approach allows the team to partner with you, your patients, and your patients families and caregivers across the continuum of care. Tufts Health Public Plans considers members with certain conditions and experiences as candidates for integrated care management services. Such candidates may: Be currently inpatient in a level III nursery, i.e., a neonatal intensive care unit (NICU) or special care nursery Require supportive services beyond the discharge planning period if they are currently inpatient or have recently been discharged from an inpatient setting Experience frequent hospitalizations (two or more admissions within a 60-day period) Tufts Health Public Plans Provider Manual CHAPTER 4A: CARE MANAGEMENT

18 Experience frequent emergency department (ED) visits (three visits within a six-month period) Have specific diagnoses, such as: multiple trauma; head injury; progressive debilitating musculoskeletal or neurological disorders; transplants; cystic fibrosis; cerebral palsy; major mental illness; a chronic medical condition including asthma, cancer, congestive heart failure, depression, diabetes, HIV/AIDS, or hypertension; or serious emotional disturbances Have coexisting diseases and/or comorbidities affecting the recovery process Have a terminal diagnosis Have experienced a catastrophic event Have recent medical admissions for alcohol/substance abuse You can refer a Tufts Health Public Plans patient for evaluation for any of our integrated care management services by calling us at To support the integrated care approach, we encourage you to share information about your Tufts Health Public Plans patients with us and their other health care providers. We offer the following form to help you and your patients share health information: Combined MCE Behavioral Health Provider/Primary Care Provider Communication Form promotes care coordination between your patients primary care providers (PCPs) and BH providers. COMPLEX CARE MANAGEMENT Our complex care management program is for members with hard-to-manage, unstable, and/or long-lasting medical conditions. Members in this program get help from a team of dedicated health care professionals who can help them navigate the health care delivery system to facilitate appropriate care and access to services. Our complex care management team provides a range of services to help your Tufts Health Public Plans patients achieve better health outcomes. These services include: Performing risk assessments and evaluations Coordinating care Providing targeted health education for your Tufts Health Public Plans patients and their families Providing a link between clinical services and available community resources Facilitating communication between you and your Tufts Health Public Plans patients Educating and empowering your Tufts Health Public Plans patients to take an active role in managing their health Working to decrease ED visits and acute inpatient lengths of stay Using health care resources appropriately and in line with clinical guidelines Tufts Health Public Plans Provider Manual CHAPTER 4A: CARE MANAGEMENT

19 We identify medically complex members at risk for future hospitalization, significant health care needs, or high health care costs through predictive software and direct referral appropriately by evaluating: High predictive risk score Frequent ED utilization Frequent medical inpatient admissions Intensive BH needs Diagnosis of severe or persistent mental illness (SPMI) Other ways medically complex members are identified include: Physicians, nurse practitioners, medical directors, and utilization management registered nurses identify the majority of members who warrant complex care management. Members are identified following admission to an acute or rehabilitation hospital for a complex medical episode or a catastrophic medical event. Members with complex needs may be referred into the program from employers, medical providers, and other Tufts Health Public Plans programs. Members are welcome to self-refer as well. Additionally, members with multiple health conditions, intensive medical needs, or any of the following conditions may benefit from complex care management: Cancer HIV/AIDS Organ transplantation Severe disability or impairment We strive to help your Tufts Health Public Plans patients attain optimal functional well-being, initiate early interventions to avoid complications, and minimize the onset of secondary disabling conditions. We encourage you to refer your patients who could benefit from complex care management services by calling us at Tufts Health Public Plans Provider Manual CHAPTER 4A: CARE MANAGEMENT

20 BEHAVIORAL HEALTH INTENSIVE CLINICAL MANAGEMENT (ICM) We provide individualized coordination of care across the treatment spectrum through intensive clinical management (ICM) for your Tufts Health Public Plans patients with intensive behavioral health needs. We employ ICM interventions to optimize functioning within the community, to manage symptoms and illness, and to prevent relapse. ICM managers outreach to members and collaborate with inpatient providers, outpatient teams, and state agencies, including the Department of Mental Health (DMH) and the Department of Children and Families (DCF). We offer ICM to your Tufts Health Public Plans patients who: Have the highest risk for recurrent hospitalizations, such as those who have had two or more authorized acute BH admissions over the course of 60 days Demonstrate underutilization or noncompliance with recommended community-based services Experience a catastrophic event Have a history of multiple hospitalizations Are newly diagnosed with a major mental illness Have special needs or cultural issues that require multiple agencies to coordinate service delivery Have several family members who currently use intensive services, requiring multiple agencies to coordinate service delivery ICM may include community support program services, family stabilization services, crisis prevention planning, and follow-up support for medication visits, pharmacy review, or PCP access and coordination. We will consider whether your patients might benefit from having an intensive clinical manager attend a treatment planning session(s), or from our sharing clinical information with various health care providers. If so, we will assign an intensive clinical manager to participate in treatment planning and help coordinate your patients care by working with you, your patients, and your patients significant others. Your patients may discontinue participation in our ICM program after any of the following events: Using the ICM master treatment plan and reaching their highest level of functioning Moving to a long-term care facility Achieving the maximum benefit from ICM services Disenrolling from Tufts Health Public Plans Your Tufts Health Public Plans patients, their families, or their legal guardian may also opt out of ICM participation. For more information about ICM or to refer a patient, call us at Tufts Health Public Plans Provider Manual CHAPTER 4A: CARE MANAGEMENT

21 SOCIAL CARE MANAGEMENT Our social care management program helps members and their families, when appropriate, by coordinating, monitoring, evaluating, and advocating for services that address barriers to care and affect members health. Social care managers work collaboratively with other Tufts Health Public Plans clinicians, providers, community-based support, and other resources. The social care managers provide both telephonic and on-site support to assist members. Social care managers can help your patients with: Applying for food stamps Applying for benefits such as Supplemental Security Income (SSI) and Social Security and Disability Insurance (SSDI) Coordinating services with the Department of Transitional Assistance (DTA) and/or the Social Security Office Locating emergency shelter Getting information about programs to help pay for utilities Finding disability support groups Coordinating transportation to medically necessary appointments, when appropriate and applicable Getting counseling or medical or behavioral health services Getting other community services in addition to services we provide You can refer a Tufts Health Public Plans patient for social care management by calling us at CLINICAL COMMUNITY OUTREACH Our clinical community outreach program is a two- to six-week program that helps members become familiar and involved with available services. Our team reaches out to members who are not currently engaged with you or other health care providers and who could benefit from our care management services. The team will collaborate with your office to: Schedule appointments with members Increase member participation in available services, such as: Preventive health care Health maintenance programs Community resources Assess barriers to care for members Transition members to longer-term care management, as appropriate Schedule overdue follow-up appointments We may contact you to get current information for your Tufts Health Public Plans patients who could benefit from our clinical community outreach or other programs that help them become more engaged in their health care. Tufts Health Public Plans Provider Manual CHAPTER 4A: CARE MANAGEMENT

22 TRANSITIONS OF CARE We initiate care transition plans after your Tufts Health Public Plans patients leave an acute, subacute, or skilled nursing facility; transitional care unit; or rehabilitation setting. Through our programs for medical, behavioral health, and/or substance abuse transitions of care, we strive to: Identify and facilitate appropriate care and services for your patients who would benefit from interventions Ensure your patients know and understand their condition(s) Educate your patients about self-managing their condition(s) Provide individualized and integrated short-term care management to each of your patients Identify incidences of, and develop interventions to improve, underused or overused services Improve your patients overall health Our care managers also work with ancillary providers (e.g., visiting nurse associations, durable medical equipment vendors) to ensure your patients get timely services. Transitional care can last from 6 to 12 weeks. Additionally, we offer an enhanced care transition program to work more closely with you and your Tufts Health Public Plans patients with a history of substance abuse. We can support the care you provide your patients by helping to: Improve patient access to care and transitions of care Reduce readmissions and ED utilization Increase patient engagement with appropriate health care providers and care transition services Partner with detoxification providers to ensure your patients receive the appropriate level of care You can refer a patient for the medical, behavioral health, or substance abuse care transition program by calling us at Disease management Disease management is our clinical and quality management of chronic conditions, such as asthma, diabetes, heart failure, and chronic obstructive pulmonary disease (COPD). We often provide disease management services in conjunction with complex care management services for conditions such as high-risk pregnancy and HIV/AIDS. When your Tufts Health Public Plans patients have complex issues as a result of disease or need more intensive intervention, we coordinate care through our care management program. Our disease management program consists of: Patient education by mail, by phone, and in person Information on the use of evidence-based clinical guidelines Coordination of services from our partners and other resources Identification of and referral to more intensive care management as appropriate Tufts Health Public Plans Provider Manual CHAPTER 4A: CARE MANAGEMENT

23 Referrals to disease management come through Tufts Health Public Plans staff, providers, facility staff, vendors, patients, and/ or patients families. We also identify patients with asthma, diabetes, heart failure, and COPD using processes that include reviewing claims for codes associated with treating these chronic conditions. Multidisciplinary staff members collaborate with other clinicians and licensed professionals at Tufts Health Public Plans to evaluate eligibility for disease management services. You can refer a patient for disease management by calling us at Our staff also works with you to help your patients achieve the disease management goals and outcomes you set with them. We consider your patients with complex issues or those who need more intensive intervention(s) for other care management services. Also, twice a year we will send you a report listing your Tufts Health Public Plans patients with asthma and/or diabetes who are overdue for important health-related screenings, or who may benefit from a discussion about medication usage. ASTHMA Tufts Health Public Plans asthma disease management program actively supports the personalized asthma action plan you should create for your patients to outline steps they can take to manage their asthma. Our program provides your Tufts Health Public Plans patients with information about treatment, prevention of exacerbations, identification of triggers, and strategies for self-management. We also offer your Tufts Health Public Plans patients with asthma a free in-home asthma education program through a visiting nurse, who can give your patients information and tools to help them understand asthma and its causes, triggers, and symptoms. Additionally, our asthma program can provide your patients with: Family education Home environmental assessments Dust mite covers for beds and pillows Reminders about managing asthma DIABETES To improve outcomes for patients with type 1, type 2, and gestational diabetes, we offer your Tufts Health Public Plans patients a diabetes disease management program. Through the program, we give your patients educational materials about diabetes and remind them of annual tests, such as HbA1c and dilated eye exams, which are essential to preventing secondary complications. We also offer additional wellness incentives. Visiting nurse services also provide both ongoing medical care and, when appropriate, diabetes education for your homebound patients. Through our partnership with Neighborhood Diabetes, your Tufts Health Public Plans patients with diabetes can receive: Free glucose meters and training on how to use them Information about healthy eating habits and regular foot and eye care Assistance getting testing supplies, with free delivery You can refer a patient for disease management by calling us at Tufts Health Public Plans Provider Manual CHAPTER 4A: CARE MANAGEMENT

24 Health and wellness support HEALTH COACHING Our health coaches are specially trained health professionals available seven days a week, 24 hours a day, to talk to your Tufts Health Public Plans patients about their immediate or everyday health concerns. Our health coaches are licensed medical professionals who can help your patients with things like making healthier food choices, understanding their medication, and learning when to report symptoms to you or other health care providers. We offer free health coaching to your patients in a variety of ways: Our free 24/7 NurseLine 888-MY-RN-LINE ( ) Healthy reminders throughout the year depending on your patients health needs, we may send reminders about important tests or information they should discuss with you Information on local health classes and services we have information about health classes and other health-related services in your community. We can provide your patients with information on smoking cessation, weight loss, disease management, or stress-reduction programs in their community. We want to keep you informed about the care your patients receive in our health coaching program. If any of your patients are working with us, a Tufts Health Public Plans care manager may send you a letter. We may also contact you to request information about any of your patients who could benefit from health coaching. To refer a patient for health coaching, please call us at HEALTH LIBRARY Our online Health Library offers easy-to-understand articles on thousands of health topics for your Tufts Health Public Plans patients. You and your patients can also use our Online Health Guide to access health decision tools, symptom and drug interaction checkers, a Spanish-language health guide, and more. WELLNESS SERVICES We also offer your Tufts Health Public Plans patients wellness support, including: Providing your patients with general health information Covering Tufts Health Together (MassHealth) patients who are children and adolescents under age 21 for Early Periodic Screening, Diagnosis, and Treatment (EPSDT) and Preventive Pediatric Health Care Screening and Diagnosis (PPHSD) services (for more information, see our EPSDT resources page and our EPSDT and PPHSD Screening Services Payment Policy, which includes information on additional reimbursement for conducting the screenings) Coordinating maternal and child health services, as detailed in the following section Tufts Health Public Plans Provider Manual CHAPTER 4A: CARE MANAGEMENT

25 Maternal and child health program We work closely with you to ensure your pregnant Tufts Health Public Plans patients receive ongoing prenatal care, and we can help coordinate postpartum care for new mothers and their children. Our maternal and child health services complement the care you provide. PRENATAL REGISTRATION While pregnancy care providers will primarily coordinate a patient s obstetrical health care needs, we can help. After you notify us of a Tufts Health Public Plans patient s pregnancy using our Prenatal Registration Form, your patient becomes eligible for a variety of prenatal services and counseling. In addition, you can receive an extra $40 if you report the pregnancy within the patient s first trimester, or $20 if you report the pregnancy within the patient s second trimester. To get the reimbursement, submit the Prenatal Registration Form using CPT code 0501F and diagnosis code V22.1. Once you complete the form and fax it to us, we generate a precertification number and send you a letter of acknowledgment for our global obstetrical package that covers your Tufts Health Public Plans patient s routine obstetrical ultrasound, prenatal nutritional counseling, care management, and other routine prenatal and postpartum services. We will also notify your Tufts Health Public Plans patient about childbirth and/or breastfeeding classes, and the importance of having a postpartum visit. FREE SERVICES AND EXTRAS As part of the care you offer pregnant women who belong to Tufts Health Together, please remind them to take advantage of these services we offer: Help choosing an OB/GYN, certified nurse midwife, or other pregnancy care provider, and a pediatrician or primary care provider (PCP) for their baby Help coordinating services for medically and socially high-risk pregnancies through our care management program, the Early Intervention Partnership Program, or other available community resources Free prenatal and postpartum home visits from a visiting nurse Special or prescription formulas In addition, we offer your eligible patients many EXTRA benefits. We will also send your pregnant Tufts Health Together patients our award-winning Grow Healthy Together calendar, which includes information about the new baby s development during and after pregnancy, with PCP visit reminders. Tufts Health Public Plans Provider Manual CHAPTER 4A: CARE MANAGEMENT

26 NOTIFICATION OF BIRTH To ensure continuity of care for mothers and newborns, and to facilitate the enrollment of newborns into MassHealth, the admitting or delivering hospital must notify us of each delivery by phone at or by fax at The facility must also submit a Notification of Birth form (NOB-1) to MassHealth for Tufts Health Together members within 30 days after the birth. You must choose Tufts Health Public Plans for the mother s plan in Section I: Mother s Information on the NOB-1 form. Remember: You can refer a patient for any care management services by calling us at B Tufts Health Public Plans Provider Manual CHAPTER 4A: CARE MANAGEMENT

27 CHAPTER 4B: BEHAVIORAL HEALTH Our in-house behavioral health (BH) team is here to help you access varying levels of services for your Tufts Health Public Plans patients based on their needs, intensity of utilization, and/or coexisting medical conditions. Refer to this chapter for information about: BH program BH services Medical necessity and clinical criteria BH services authorization Denials and appeals Administrative appeals Patient care coordination Treatment and discharge planning Social care management Medical records compliance Adverse incident reporting Criteria and procedures for all BH services o o o Discharge criteria Continued-stay criteria Continued-stay review procedure Outpatient services o o o o o Outpatient therapy and medication management Opioid treatment services Acupuncture detoxification Electroconvulsive therapy (ECT) Psychological testing Emergency services o o o o Emergency Services Program (ESP) providers Mobile crisis intervention Youth mobile crisis intervention Community crisis stabilization (CCS) Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

28 Non-24-hour diversionary services o o o o o o Community support programs (CSPs) Family stabilization team Structured Outpatient Addiction Program (SOAP) Psychiatric day treatment Intensive outpatient program (IOP) Partial hospital program (PHP) 24-hour diversionary services o o o o Community-based Acute Treatment (CBAT) for children and adolescents Dual Diagnosis Acute Residential Treatment (DDART) Enhanced Acute Treatment Services (EATS) Observation o Acute treatment services (ATS) for substance abuse (Level 3.7) o Clinical stabilization services (CSS) (Level 3.5) o Transitional care units (TCU) Inpatient services o o o Inpatient substance abuse services (Level 4.0 detoxification) Inpatient psychiatric services Transfers Children s Behavioral Health Initiative (CBHI) services o o o o o o Child Adolescent Needs and Strenghts (CANS) requirements Intensive care coordination (ICC) Family support and training (FS&T) In-home behavioral services (IHBS) In-home therapy (IHT) Therapeutic mentoring (TM) For information about BH provider responsibilities, please see Chapter 2. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

29 BH program MEDICAL NECESSITY AND CLINICAL CRITERIA We authorize medically necessary BH services that: Prevent, diagnose, alleviate, correct, or cure the worsening of conditions that endanger your patient s life; cause suffering or pain; threaten to cause or aggravate a disability, or result in illness or infirmity Cannot be replaced with a less intensive level of care Are substantiated by clinical records Meet professional health care standards We will only approve service requests that meet clinical criteria for a particular service. Use the links on pages 1 2 for information regarding our service criteria. BH SERVICES AUTHORIZATION Please refer to the authorization procedure for each of the particular services listed previously or call us at for more information about authorizations. When we approve an admission, procedure, or service, we will notify you within 24 hours and send written or electronic confirmation to you within two business days. The authorization letter will indicate the services we will cover. Always verify the eligibility of Tufts Health Public Plans members at the time you render services. For more information about checking eligibility, please see Chapter 2. DENIALS AND APPEALS We will not pay for any unauthorized services. When we deny, reduce, modify, or terminate an admission, continued inpatient stay, or the availability of any other BH service, we will notify you within 24 hours and send written or electronic confirmation to you and your Tufts Health Public Plans patient within one business day. Our notice will include information on the appeals process and an Authorized Representative Form for your Tufts Health Public Plans patient to sign if he or she would like you to appeal the denial on his or her behalf. Please see Chapter 7 for more information. ADMINISTRATIVE APPEALS We will administratively deny payment for care if you do not follow our authorization policies and procedures. Also, if you do not notify us of a Tufts Health Public Plans patient s admission, we will administratively deny payment when we have not given authorization for those days. Our approval for subsequent days is subject to clinical criteria. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

30 PATIENT CARE COORDINATION Our BH clinicians and care managers work with you to coordinate care for your Tufts Health Public Plans patients. Together we can ensure your patients receive optimal health care. We will work with you to: Continue improving the health of your patients and their families Ensure your patients have timely and easy access to appropriate BH care Involve your patients in their treatment planning and recovery Provide effective BH care Enhance continuity and coordination of care among BH providers Our services include: Monitoring treatment compliance Reviewing your patients ongoing service needs Helping you plan your patients discharge Providing you and your patients with information on community-based services We recognize more than one provider may contribute to the care of your patients. We strongly encourage providers, particularly primary care and behavioral health providers, who are caring for Tufts Health Public Plans patients to share relevant information regarding diagnoses, medication, and/or treatment to help improve health outcomes. TREATMENT AND DISCHARGE PLANNING BH treatment and discharge planning are important components of our overall utilization management (UM) program. Treatment planning BH treatment planning focuses on identifying barriers to your Tufts Health Public Plans patients ability to follow through with the treatment and discharge plan. We require you to complete an initial BH treatment plan within 24 hours of patients admission to an acute care or 24-hour diversionary service, and to complete a multidisciplinary treatment plan within 24 hours of patients admission. For children and adolescents, we expect a parent or guardian to be involved with the treatment planning. If an adult patient has a guardian, please also include that guardian in treatment planning. As appropriate, we suggest treatment planning meetings include the patient, the patient s family, other providers, and/or other caregivers. If the patient receives BH care management from Tufts Health Public Plans, please also involve the patient s Tufts Health Public Plans care manager, as appropriate. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

31 Discharge planning Discharge planning is an integral component of BH treatment planning that begins at admission and continues throughout the patient s stay. For children and adolescents, we expect a parent or guardian to be involved with the treatment planning after discharge. Whenever possible, schedule a discharge meeting so that the patient, the patient s family, and/or other caregivers are aware of the discharge plan. If the patient receives Tufts Health Public Plans BH care management services, please invite the care manager to the discharge planning meeting. As a key part of discharge planning, we urge BH providers to schedule two outpatient therapy appointments within seven days of discharge from an inpatient setting and, if appropriate, a medication appointment within 14 days of discharge. We recommend using step-down services, such as partial hospitalization, to help your patients successfully transition back into the community. We also cover and encourage the use of transitional services, such as bridge visits and community support programs, to help patients with their transition whenever possible. SOCIAL CARE MANAGEMENT Our social care managers can assist with addressing your Tufts Health Public Plans patients nonmedical and social issues that may be barriers to care. Please see Chapter 4A for more information or call us at to reach our care managers. MEDICAL RECORDS COMPLIANCE Please prepare and complete an individualized written assessment and treatment plan for all Tufts Health Public Plans patients you treat within the following time frames: Acute inpatient treatment within 24 hours of admission Diversionary treatment within 48 hours of admission Outpatient treatment before the third outpatient visit Please see the behavioral health medical record audit tools that identify the required components. ADVERSE INCIDENT REPORTING Tufts Health Public Plans requires that BH providers immediately report adverse incidents to us, including but not limited to any: Death required by M.G.L. c to be reported to the Medical Examiner, or in which the Medical Examiner takes jurisdiction Nonmedicolegal (i.e., malpractice-related) deaths Occurrence that represents actual or potential serious harm to the well-being of a Tufts Health Public Plans member receiving services managed by a Tufts Health Public Plans provider Serious injury resulting in medical hospitalization Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

32 Injury requiring an acute-care hospital admission Injury that requires medical attention but does not result in an acute-care hospital admission Sustained injury while in a 24-hour program Any absence without authorization (AWA), or any AWA involving a patient under the age of 18 or a patient admitted or committed pursuant to M.G.L. c , who is also at high risk of harm to self or others Unscheduled event(s) resulting in a Tufts Health Public Plans patient temporarily evacuating a program or facility (e.g., a fire to which a fire department responds) Sexual assault or alleged sexual assault Physical assault or alleged physical assault on or by a Tufts Health Public Plans patient DMH restraint and seclusion regulation violations or alleged violations If any situation occurs at a BH provider site that fits the criteria for an adverse incident, you must report the incident to a Tufts Health Public Plans care manager by calling us at the same day the incident occurs. If you are unsure if we would consider an event an adverse incident, please call us to discuss the event or incident. After you report the incident, please fax a completed Adverse Incident Report Form to us at the same day you call us to report the incident. Please present all information related to the nature of the incident, including the parties involved (names and telephone numbers) and your Tufts Health Public Plans patient s current condition. In resolving your adverse incident report, we will: Gather all necessary data from you Conduct a safety and risk assessment to ensure your patient is not at immediate risk of harming himself or herself, or others (if we determine the patient is at immediate risk, we will initiate an emergency response plan) Conduct a preliminary investigation that may include interviewing additional providers or the patient Have our BH medical director or associate medical director review the adverse incident report Complete a Critical Incident Response Report Inform the appropriate state agency, if necessary Recommend action steps or follow-up activities, if indicated For more information, or if you have questions about working with us on these types of incidents, please call us at Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

33 BH services We cover a range of BH benefits and services for your Tufts Health Public Plans patients. Please take into consideration psychosocial, occupational, and cultural and linguistic factors when providing care to your Tufts Health Public Plans patients. These factors may influence your risk assessment and service decisions. CRITERIA AND PROCEDURES FOR ALL BH SERVICES The following criteria and procedures apply to all services except where noted differently or as not applicable under that particular service. Discharge criteria For all services, patients must meet any ONE of the following criteria for discharge: They no longer meet admission criteria and/or meet criteria for a different level of care (higher or lower). They have achieved treatment goals. They have a support system that agrees to follow through with care, are able to be in a less-restrictive environment, and have all appropriate community-based linkages in place. They withdraw consent for treatment, or the parent, guardian, or authorized representative withdraws consent. They do not appear to be participating in the treatment plan or making progress toward goals, with little to no expectation of any further progress. They have reached the maximum benefit for that service. Please see service descriptions for details. Continued-stay criteria To continue receiving a BH service, your Tufts Health Public Plans patients must meet ALL of the following criteria: They continue to meet admission criteria, and a different level of care is not appropriate. They continue to benefit from the treatment. They have made progress toward identified goals. They are receiving treatment and services in a structured and goal-directed manner. They have family/guardian(s) participating in treatment, if needed. They are receiving individualized and specific treatment planning, including provider s orders, special procedures, contraindications, and other medications. Their provider either has tried medication, if applicable, or ruled it out. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

34 Additionally, you must: Assess that your Tufts Health Public Plans patients will have decreased functioning if discharged from this level of care. Ensure your Tufts Health Public Plans patients receive different treatment(s) if symptoms change, or if they make or fail to make progress. Have strategies in place to address any possible treatment plan changes. Have a treatment plan that documents treatment coordination and coordination with state agencies, if involved. Continued-stay review procedure If your Tufts Health Public Plans patients need additional services beyond those we initially authorize at the time of admission, we must perform a continued-stay review and authorize service continuation. Please call us at prior to the expiration of the initial authorization to conduct a continued-stay review. We will not reimburse you for any interval between the last covered day and the date of next contact if you notify us after the initially authorized time frame. Please have the following information available for a continued-stay review: Current diagnosis and treatment plan, including provider s orders, special procedure, and medications Rationale for continued care Description of the patient s response to treatment since the initial authorization or last continued-stay review Current mental status, discharge plan, and discharge criteria, including actions taken to implement the discharge plan Proposed course of treatment during the continuation period Any medical conditions needing treatment (routine medical care is included in the per diem rate) Any potential barriers to discharge and plans to address such barriers OUTPATIENT SERVICES Outpatient therapy and medication management Outpatient services are treatment interventions provided in a provider s office, an ambulatory care unit, an outpatient clinic, or another location that does not involve an overnight stay. Outpatient services help your Tufts Health Public Plans patients function at optimum levels and address the biological and psychosocial, acute or chronic stressors affecting their lives. Outpatient services may include individual, group, family, or couples therapies and may occur in a clinic, hospital outpatient department, community health center, or provider office. As clinically appropriate, your Tufts Health Public Plans patients may receive treatment at home. We authorize outpatient services based on medical necessity criteria. You may find outpatient services appropriate for your patients at any time, including after a discharge from a more acute level of care. Outpatient services are generally time limited, goal directed, and use a master treatment plan as a guide. In general, your patients will have measurable and need-specific treatment goals. For your patients using more than one treatment modality (e.g., individual and group therapies), the treatment plan and documentation should reflect coordination of care. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

35 We offer collateral contact (face-to-face contact or telephonic communication of at least 15 minutes) to coordinate your Tufts Health Public Plans patients care and treatment, review their progress, and/or revise treatment goals. Collateral contacts may include your Tufts Health Public Plans patients teachers, principal, guidance counselor, day care provider staff, previous therapist, outreach program staff, after-school program staff, and/or community center staff. Collateral contact does not include inter-agency communication. Outpatient therapy and medication management level-of-care criteria Admission criteria To receive outpatient care, your Tufts Health Public Plans patients must: Demonstrate symptoms consistent with a primary DSM-IV diagnosis of psychiatric disorder and/or substance-use problem Be motivated and engaged, agree to comply with treatment plans, and have a system in place to ensure followthrough with the treatment plan Maintain a current level of functioning through outpatient treatment Have impaired level of functioning in areas such as self-care, work, family living, and social relations and outpatient care will help increase level of functioning Experience increased intensity or duration of symptoms with a diagnosis of mental illness and/or substance use Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they have a(n): Organic mental disorder (e.g., delirium, dementia, amnesia) and other cognitive disorders Mental disorder due to a primary medical condition Please note: Exclusion criteria apply unless patients have a DSM-IV diagnosis, treatable at this level of care, that is the focus of the intervention. Continued-stay criteria Besides the criteria listed on page 7, there are no additional criteria. Discharge criteria Besides the criteria listed on page 7, there are no additional criteria. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

36 Outpatient therapy authorization procedure Your Tufts Health Public Plans patients are eligible for 12 outpatient visits without prior authorization to an in-network provider each benefit year. For information on the time frame of the benefit year, please refer to the medical and behavioral health benefit summary grids. Please note: The initial 12 visits follow your Tufts Health Public Plans patients if coming from or going to another outpatient facility. It is your responsibility to monitor the total number of visits the patient has had. Continued-stay review procedure Besides the criteria listed on page 9, if your patients require treatment beyond the initial 12 visits, you must submit a Behavioral Health Outpatient Psychotherapy Authorization Form before the 12th visit. We recommend that you submit this form at least three weeks prior to the last covered visit to ensure no treatment disruption. We base continued outpatient treatment authorization on clinical/medical necessity criteria. Our care managers can assist in coordinating care if your patients have more than one provider. Child and Adolescent Needs and Strengths (CANS) As part of the Children s Behavioral Health Initiative (CBHI), we require our outpatient providers to be certified in the Child and Adolescent Needs and Strengths (CANS) tool and to use the CANS tool as part of an initial BH assessment when conducting outpatient therapy for our MassHealth members under the age of 21. Outpatient providers must complete a CANS assessment for inpatient and outpatient visits, and all other CBHI services. MassHealth requires providers to update the CANS assessment through the Virtual Gateway Children s Behavioral Health Initiative (CBHI) Application every 90 days. Medication management and group therapy authorization procedure Neither medication management visits with an in-network BH provider nor group therapy counts against the annual 12 outpatient visits benefit, and therefore neither requires prior authorization. Opioid treatment services Methadone treatment services include daily administration of methadone to your Tufts Health Public Plans patients (as outlined in treatment guidelines) addicted to opiates, combined with regular counseling, medical screening, urine testing, HIV/AIDS education, care management, and other appropriate services. Treatment goals include eliminating opiate intravenous drug use, evaluating and eliminating the use or abuse of alcohol or other drugs, improving your Tufts Health Public Plans patients health status, and improving their level of functioning. Your Tufts Health Public Plans patients may receive methadone treatment on a short-term (detoxification) or long-term basis, though the duration of service will vary depending on individual need. We allow daily methadone dosing and up to four sessions per week of individual, family, or group counseling. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

37 Opioid treatment services level-of-care criteria Admission criteria To receive opioid treatment services, your Tufts Health Public Plans patients must: Have an active DSM-IV Axis I diagnosis of opiate dependence Have been physiologically dependent on an opiate drug for at least one year Not respond well to interventions and other treatment Have evident and documented signs and symptoms of opioid withdrawal Meet all appropriate Drug Enforcement Agency (DEA) and Department of Public Health (DPH) regulations Have an acute risk of relapse or continued opiate dependence and need a medication prophylactic, regular counseling, and individualized urine monitoring Have biomedical conditions and opiate addiction-based complications that require medical monitoring and skilled care most effectively managed at this level of care Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they: Have medical problems requiring hospitalization Have an illness that would interfere with methadone treatment Are experiencing acute withdrawal from opioids, sedative hypnotics, or stimulant drugs Continued-stay criteria Besides the criteria listed on page 7, there are no additional criteria. Discharge criteria Besides the criteria listed on page 7, there are no additional criteria. Continued-stay review procedure There are no additional requirements besides those listed on page 8. Opioid treatment services authorization procedure We do not require prior authorization for opioid treatment from an in-network provider. Please see Chapter 4D for information about out-of-network authorization requests. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

38 Acupuncture detoxification Your Tufts Health Public Plans patients who, during withdrawal, experience physiological dysfunction not severe enough to threaten their life or significant bodily functions but who require medication for withdrawal from a substance (e.g., alcohol, barbiturates, benzodiazepines) may receive outpatient acupuncture detoxification. Treatment may include motivational and supportive counseling focused on further engaging your Tufts Health Public Plans patients, along with acupuncture treatment and participation in ongoing substance-use outpatient treatment and self-help groups. If your Tufts Health Public Plans patients experience a serious episode of excessive substance use or withdrawal complications and choose to receive outpatient acupuncture detoxification, they must do so in a clinic setting under a provider s direction. Please note: For Tufts Health Together members, acupuncture for pain management and anesthesia must be performed by an MD or DO. You may use acupuncture as an ancillary treatment during detoxification or postdetoxification. Acupuncture detoxification level-of-care criteria Admission criteria To receive acupuncture detoxification, your Tufts Health Public Plans patients must: Have a history of substance-use disorder Experience symptoms of withdrawal and disordered behavior that interfere with activities of daily living but not to a degree that poses a risk to themselves or others Have adequate support systems to allow for success in an outpatient setting Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they: Are actively suicidal or homicidal Have a comorbid psychiatric diagnosis that requires inpatient treatment Continued-stay criteria In addition to the criteria listed on page 8, your patients must: Experience symptoms of such intensity that, if discharged, would require a more intensive level of care Receive individualized and specific treatment planning, including provider s orders, special procedures, contraindications, and other medications Discharge criteria There are no additional criteria besides those listed on page 8. Acupuncture detoxification service authorization procedure Call a Tufts Health Public Plans BH care manager at to get initial authorization for outpatient acupuncture detoxification services either prior to or on the first day of treatment. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

39 Please have the following information about Tufts Health Public Plans patients available when you request prior authorization: Tufts Health Public Plans member ID number Name, gender, date of birth, and city or town of residence Facility s or provider s name and requested duration of treatment DSM-IV diagnosis (all five axes, as appropriate; we will accept a provisional diagnosis) A recommended treatment plan Medication history Substance-use history Rationale for this level of care Continued-stay review procedure There are no additional requirements besides those listed on page 8. Electroconvulsive therapy (ECT) A Department of Mental Health (DMH)-licensed hospital or facility can administer ECT for your Tufts Health Public Plans patients with: Significant psychiatric impairment, with or without psychosis, that does not respond to adequate trials of medication or when medication is contraindicated Previous therapeutic response to ECT Severe impairment due to life-threatening behaviors (e.g., refusal to eat or drink, compulsive and/or impulsive suicidal tendencies) when the latency of action of medication places your Tufts Health Public Plans patients at added risk Before scheduling ECT administration, please complete a work-up, including medical history, physical examination, and any indicated preanesthetic lab work to determine that your Tufts Health Public Plans patients do not have contraindications to ECT and that no less intrusive alternatives to ECT exist or are likely to be successful. Your Tufts Health Public Plans patients must provide separate written informed consent to ECT on forms provided by the DMH. Consent to other forms of psychiatric treatment does not include consent to ECT. You must inform your Tufts Health Public Plans patients of the risks and benefits of this procedure and of any alternative somatic or nonsomatic treatments. Your Tufts Health Public Plans patients may receive ECT on an outpatient or inpatient basis, depending on their mental status. ECT level-of-care criteria Administration criteria To receive ECT, your Tufts Health Public Plans patients must meet the following criteria: Agree ECT is desirable based on a clear understanding of ECT s risks and benefits, as well as the existence and possible success of alternative treatments Provide written consent, or the parent, guardian, or authorized representative provides written consent Additionally, the treating provider and facility must meet all applicable state requirements regarding preadministration testing, consent, and independent review. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

40 ECT authorization procedure: Outpatient Contracted general hospitals and hospital-licensed community health centers licensed to provide ECT may provide this service to your Tufts Health Public Plans patients. ECT provided in an outpatient setting does not require prior authorization. ECT authorization procedure: Inpatient Contracted and licensed inpatient facilities may provide ECT treatment. ECT provided in an inpatient setting does not require prior authorization. Psychological testing Psychological and neuropsychological assessments use standardized tools to gain an understanding of your Tufts Health Public Plans patients functioning, including aptitudes, cognitive processes, emotional conflicts, and type and degree of psychopathology. Such assessments can determine differential diagnoses and assess overall cognitive functioning in relation to your patients mental health or substance-use status, and may have important treatment-planning implications. Licensed psychologists in an independent practice or agency setting may perform psychological testing on your Tufts Health Public Plans patients. Psychology assistants (doctoral level or doctoral candidates) may test and interpret results, provided the test occurs in a licensed clinic setting and a qualified licensed psychologist directly supervises and co-signs. Psychology assistants under the supervision of a psychologist in an independent practice setting may not test your Tufts Health Public Plans patients. Please note: Most Tufts Health Public Plans inpatient and acute treatment facilities have an all-inclusive per diem rate that covers any needed psychological and neuropsychological testing. Therefore, we do not reimburse individual providers for psychological testing done during the course of an inpatient stay or at an acute treatment program. Psychological testing may be appropriate for your Tufts Health Public Plans patients if, for example: Their symptoms indicate a new or different diagnosis. Their functional status has markedly changed, and assessment will assist in establishing appropriate levels of care and treatment planning. The evaluation is directly relevant to your Tufts Health Public Plans patients mental health status and treatment needs. The testing is part of a coordinated treatment plan in collaboration with other BH providers. Psychological and neuropsychological diagnostic procedures or tests you use with your patients must be individually administered and published, valid, and in general use, as evidenced by their presence in the current edition of the Mental Measurement Yearbook or by their conformity to the American Psychological Association s Standards for Educational and Psychological Testing. Reimbursable tests Contingent upon clinical/medical necessity, we may authorize the following psychological tests: Cognitive battery including either the Wechsler Intelligence Scales or the Stanford-Binet Intelligence Scale, or other standardized test of general intellectual functioning, which you must administer individually Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

41 Projective battery including at least two of the following types of tests or their age-appropriate equivalents: Rorschach Test Thematic Apperception Test (TAT) Tasks of Emotional Development (TED) Minnesota Multiphasic Personality Inventory (MMPI) Personality Assessment Inventory (PAI) One or more types of tests, including but not limited to: Figure drawing Bender-Gestalt Word association Assessment of brain damage including the Wechsler Intelligence Scales and standardized tests of memory, such as the Wechsler Memory Scale and the Benton Visual Retention Test Neuropsychological assessment including assessment of brain damage using the Halstead-Reitan or Luria-Nebraska neuropsychological battery or other tests of comparable scope or intensity, such as Boston Process Approach (BPA) battery (individual diagnostic procedures must be listed when using BPA) Unlisted service including services such as abbreviated or quick intelligence tests, or a separately administered Rorschach test Nonreimbursable tests We will not reimburse for the following tests: Self-rating forms and other paper and pencil instruments, unless administered as part of a comprehensive battery of tests (e.g., MMPI, PAI) Group intelligence tests Short-form, abbreviated, or quick intelligence tests administered at the same time as the Wechsler or Stanford-Binet tests Repetition of any psychological tests or tests provided to the same recipient within the preceding 12 months, unless documented that the purpose of the repeated testing is to ascertain whether the patient is: Following special forms of treatment or intervention (e.g., ECT) Experiencing changes relating to suicidal, homicidal, toxic, traumatic, or neurological conditions Psychological testing authorization procedure We require prior authorization for psychological testing. You must complete a Prior Authorization Request for Psychological Testing Form and fax it to us at prior to the start of testing. A psychologist will review your psychological testing request. Please note: We do not authorize periodic testing to measure your Tufts Health Public Plans patients response to psychotherapy. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

42 EMERGENCY SERVICES Emergency Services Program (ESP) providers (for Tufts Health Together members only) Your Tufts Health Public Plans patients can access contracted specialized ESP providers 24 hours a day, seven days a week, 365 days a year. ESP providers offer crisis assessment, crisis intervention, short-term crisis counseling, crisis stabilization, and mobile crisis intervention services for your Tufts Health Public Plans patients. ESP providers aim to rapidly respond, assess, and deliver a course of treatment intended to promote recovery, ensure safety, and stabilize your Tufts Health Public Plans patients crises in a manner that allows an individual to receive medically necessary services in the community or in an inpatient or 24-hour diversionary level of care. In all encounters, an ESP provider will conduct a BH crisis assessment and offer short-term crisis counseling that includes active listening and support while also providing solution-focused and strengths-oriented crisis intervention. The crisis intervention is aimed at working with your Tufts Health Public Plans patients and their families and/or other natural supports to understand the current crisis, identify solutions, and access resources and services for comfort, support, assistance, and treatment. An ESP provider will coordinate with other involved service providers and/or newly referred providers to share information (with appropriate consent) and make recommendations for the treatment plan. An ESP provider also provides your Tufts Health Public Plans patients and their families with resources and referrals for additional services and supports, such as recovery-oriented and consumer-operated resources in their community. All ESP provider encounters should minimally include the three basic components of crisis assessment, intervention, and stabilization. We believe that crisis services also require flexibility in the focus and duration of the initial intervention, as well as the individual s participation in the treatment, and that the provider should always consider the number and type of follow-up services their patients will require. ESP providers accept requests and/or referrals for ESP services directly from your Tufts Health Public Plans patients who seek them on their own and/or from any other individual or resource, such as: Family members and guardians Community-based agency staff Service providers PCPs Residential program staff School representatives State agency personnel Law enforcement representatives Court representatives After considering all available input, an ESP provider will determine the most appropriate level of care or service for your Tufts Health Public Plans patients and, when appropriate, will call a Tufts Health Public Plans BH care manager at for service authorization and/or to facilitate access and referral to the service. We will base our level-of-care determination on medical necessity criteria. For a list of ESP providers, please see the MBHP ESP Statewide Directory. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

43 Mobile crisis intervention ESP providers deliver mobile crisis intervention services in the community 24 hours a day, seven days a week, 365 days a year. Mobile crisis intervention services should be integrated into the ESP provider s infrastructure, services, policies and procedures, staff supervision and training, and community linkages. An ESP provider s mobile crisis intervention services and staff provide all ESP services for your Tufts Health Public Plans patients. The best practice for delivering crisis services is via a discreet and minimally disruptive mobile response in a natural setting, such as your Tufts Health Public Plans patients home or school, or a neutral community-based site. Delivering strengths-based and solution-focused intervention aims to resolve the crisis, mobilize natural supports, and provide rapid linkage to the right level of care. Mobile crisis intervention services include consultative and collaborative services, placing a high value on achieving a least restrictive consensus disposition while ensuring access to medically necessary services. Mobile crisis intervention services provide a short-term, on-site, face-to-face therapeutic response to your Tufts Health Public Plans patients experiencing a BH crisis. These services help patients to identify, assess, treat, and stabilize the situation and reduce immediate risk of danger to themselves or others, consistent with their risk management/safety plan, if any. Mobile crisis intervention level-of-care criteria Admission criteria To receive mobile crisis intervention services, your Tufts Health Public Plans patients must: Be in a BH crisis that phone triage could not resolve to the caller s satisfaction Need immediate intervention to attempt to stabilize their condition safely when situations do not require an immediate public safety response Demonstrate impairment in mood, thought, and/or behavior that substantially interferes with school, home, and/or community functioning In addition to the above, at least one of the following must be present: Demonstrated suicidal/assaultive/destructive ideas, threats, plans, or actions that represent a risk to self or others Escalating behavior(s) that, without immediate intervention, are likely to require a higher intensity of service In addition to the above, at least one of the following must be present: A need for clinical intervention to resolve the crisis and/or to remain stable in the community A lack of external supports as the demands of the situation exceed parent/guardian(s) strengths and capacity to maintain your Tufts Health Public Plans patients in the present living environment Please note: For your Tufts Health Public Plans patients receiving intensive care coordination (ICC), the care coordinator and/ or care-planning team must contact the ESP/mobile crisis intervention provider after efforts at triage and stabilization prove insufficient to stabilize the crisis. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

44 Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they do not consent to an evaluation and/or to mobile crisis intervention services. Continued-stay criteria Not applicable. Discharge criteria Besides the criteria listed on page 7, you may also discharge your patients if they have: A crisis assessment and other relevant information to indicate your patients need a more or less intensive level of care; the mobile crisis intervention provider facilitates transfer to the next treatment setting and communicates the risk management/safety plan to the treatment team at that setting A physical condition that necessitates transfer to an inpatient medical facility; the mobile crisis intervention provider communicates risk management/safety plan to the receiving provider No court order requiring such treatment Emergency services medical conditions and medical clearance An ESP provider delivers the majority of its services in the community rather than in hospital emergency departments. Since most individuals do not require general medical evaluation beyond screening as part of a crisis assessment and intervention, the ESP provider will assess any need for additional intervention based on the presence of an emergency medical condition coexisting with and/or contributing to the BH condition. We define an emergency medical condition as: A medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that, in the absence of prompt medical attention, could reasonably be expected by a prudent lay person who possesses an average knowledge of health and medicine to result in: Placing the health of a member or another person or, in the case of a pregnant woman, the health of the woman or her unborn child, in serious jeopardy Causing serious impairment to bodily function Causing serious dysfunction of any body organ or part Having other implications with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. 1395dd(e)(1)(B) Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

45 If your Tufts Health Public Plans patients with a BH condition develop or have an emergency medical condition, refer them to the nearest emergency room and ensure that transportation is available and provided as needed. Examples of such situations include: Drug and/or alcohol overdose Chest pain Neurological functioning, consciousness level, or motor impairment changes Premature labor or bleeding in the case of pregnancy Malignant hypertension Self-mutilation requiring immediate medical attention Emergency services authorization procedure We encourage a designated ESP provider to make an initial assessment to determine if your Tufts Health Public Plans patients meet acute service clinical criteria. We require the ESP provider to fax us the ESP assessment at , and include relevant clinical information and disposition within one business day of the encounter. We require the ESP and the admitting facility to notify us of urgent behavioral health admissions within one business day of admission. Youth mobile crisis intervention for Tufts Health Together (MassHealth) members only Youth mobile crisis intervention includes services from an ESP provider for your patients under the age of 21. Youth mobile crisis intervention services are short-term services. They are a mobile, on-site, face-to-face therapeutic response to a patient s behavioral health crisis. Goals of these services include identifying, assessing, treating, and stabilizing the situation, and reducing immediate risk of danger to the patient or others by following the patient s risk management/safety plan, if any. This service is provided 24 hours a day, seven days a week. Youth mobile crisis intervention includes: A crisis assessment Development of a risk management/safety plan if the patient/family does not already have one Crisis intervention and stabilization services for up to seven days, including, as needed: On-site, face-to-face therapeutic response intervention Psychiatric consultation Urgent psychopharmacology intervention Referrals and linkages to all medically necessary behavioral health services and supports, including access to appropriate services along the behavioral health continuum of care Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

46 For youth who are receiving Intensive Care Coordination (ICC), youth mobile crisis intervention staff will coordinate with the patient s ICC care coordinator throughout the delivery of the service. Staff will also coordinate with the patient s primary care physician, any other care management program, or any other BH providers offering services to the patient throughout the delivery of the service. Admission Criteria The patient must meet all of the following criteria for admission to this level of care: Be in a BH crisis that could not be resolved to the caller s satisfaction by phone triage Not respond to efforts by the care coordinator and Care Plan Team (CPT) to triage and stabilize the crisis and ESP/mobile crisis intervention has been contacted Need immediate intervention to stabilize his or her condition safely in situations that do not require an immediate public safety response Demonstrate impairment in mood, thought, and/or behavior that substantially interferes with functioning at school, home, and/or in the community In addition to the above, the patient must meet at least one of the following criteria: Demonstrate suicidal/assaultive/destructive ideas, threats, plans, or actions that represent a risk to self or others Continue to experience escalating behaviors and, without immediate intervention, be likely to require a higher level of service In addition to the above, the patient must meet at least one of the following criteria: Be in need of clinical intervention to resolve the crisis and/or to remain stable in the community Be in a situation that exceeds the parent s/guardian s/caregiver s strengths and capacity to maintain the patient in his or her present living environment and require external supports Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they refuse to give consent for an evaluation and mobile crisis intervention services. Continued-stay criteria Not applicable. Discharge criteria Any one of the following criteria is sufficient for discharge from this level of care: The crisis assessment and other relevant information indicate that the patient needs a more (or less) intensive level of care, and the mobile crisis intervention has facilitated transfer to the next treatment setting and ensured that the risk management/safety plan has been communicated to the treatment team at that setting. The patient s physical condition necessitates transfer to an inpatient medical facility, and the mobile crisis intervention provider has communicated the patient risk management/safety plan to the receiving provider. Consent for treatment is withdrawn and there is no court order requiring such treatment. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

47 Community crisis stabilization (CCS) CCS serves your Tufts Health Public Plans patients over the age of 18. CCS provides staff-secure, safe, and structured crisis treatment services in a community-based program that serves as a less restrictive and voluntary alternative to inpatient psychiatric hospitalization. CCS services primarily divert your Tufts Health Public Plans patients from an inpatient level of care. However, you may use the services secondarily to help your Tufts Health Public Plans patients transition from inpatient services if sufficient service capacity and admission criteria are met. CCS provides a distinct level of care where primary objectives of the active multidisciplinary treatment include: Restoring functioning Strengthening the resources and capacities of the individual, family, and other natural supports Returning to a natural and/or least restrictive setting in the community Developing/strengthening an individualized risk management/safety plan and linking to ongoing medically necessary treatment and support services CCS provides continuous 24-hour psychiatric treatment, including observation and supervision, within a structured community-based therapeutic environment while not requiring the intensive medical treatment of hospital care. CCS aims to provide sufficient structure and interventions to stabilize acute stressors and access appropriate community supports to return your Tufts Health Public Plans patients to a less restrictive level of care. Services at this level of care shall include crisis stabilization, initial and continuing biopsychosocial assessment, care management, psychiatric evaluation and medication management, peer-to-peer support, and mobilizing natural supports and community resources. CCS beds are often suited for your Tufts Health Public Plans patients with a known diagnosis who are decompensating because of an acute exacerbation of symptoms possibly secondary to medication noncompliance, new psychosocial stressors, and/or due to certain personality disorders that may complicate the Axis I diagnosis. The immediate and intense involvement of family and community support for postdischarge follow-up is an important aspect of this level of care. Please note: We include routine medical care costs in the per diem rate. You must report any medical care beyond routine care to one of our BH care managers for coordination of benefits. CCS level-of-care criteria Admission criteria To receive CCS services, your Tufts Health Public Plans patients must: Have a DSM-IV diagnosis (Axis I or II) Benefit from the program s activities conducive to alleviating the presenting crisis and allowing for discharge to a less intensive level of care within a very short period of time Have a psychiatric condition that has resulted in a decompensation that represents a high likelihood of danger to self or others developing within the next 24 hours, and no other intensive supports can provide continuous monitoring sufficient to meet your Tufts Health Public Plans patients needs Have evidence of a psychiatric condition s life-endangering acuity but have insufficient information concerning baseline functioning and family/community support to warrant inpatient psychiatric care Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

48 Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they have a(n): Organic mental disorder (e.g., delirium, dementia, amnesia) and other cognitive disorders Mental disorder due to a primary medical condition Involuntary admission Primary substance-use diagnosis Please note: Exclusion criteria apply unless patients have a DSM-IV diagnosis, treatable at this level of care, that is the focus of the intervention. Continued-stay criteria Besides the criteria listed on page 7, your patients must also show evidence of attempts to discharge or to move to a lesser level of care. Discharge criteria Besides the criteria listed on page 7, there are no additional criteria. CCS service authorization procedure We require an initial assessment to determine if your Tufts Health Public Plans patients meet adult CCS clinical criteria. A designated ESP provider may evaluate your Tufts Health Together patients. We require the ESP and the admitting facility to notify us of urgent behavioral health admissions within one business day of the admission. We require the ESP provider to fax us the ESP assessment to and include relevant clinical information and disposition within one business day of the encounter. Notification procedure Please have the following information about your Tufts Health Public Plans patients available when you notify us of your patient s urgent behavioral health admission: Tufts Health Public Plans member ID number Name, gender, date of birth, and city or town of residence Facility/provider s name and requested duration of treatment DSM-IV diagnosis (all five axes, as appropriate; we will accept a provisional diagnosis) Recommended treatment plan Medication history Substance-use history Rationale for this level of care Continued-stay review procedure There are no additional requirements besides those listed on page 8. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

49 NON-24-HOUR DIVERSIONARY SERVICES We offer non-24-hour diversionary services to help your Tufts Health Public Plans patients smoothly transition from acute care to less intensive treatment, or to divert the need for inpatient hospitalization. Your Tufts Health Public Plans patients must meet clinical/medical necessity criteria to access any diversionary services. Community support programs (CSPs) CSPs are an array of services delivered by a community-based, mobile, multidisciplinary team of professionals and paraprofessionals. These programs provide essential services to your Tufts Health Public Plans patients with a long-standing history of psychiatric or substance-use disorder, to their families, to your Tufts Health Public Plans patients who are at varying degrees of increased medical risk, and/or to children/adolescents with BH issues challenging their optimal level of functioning in the home/community setting. CSPs are also available to adults, children, and adolescents with mental health and/or substance-use disorders whose clinical profile or service utilization indicates a high risk for readmission into 24-hour psychiatric or addiction-treatment settings. CSPs provide intensive outreach and support to your Tufts Health Public Plans patients. CSPs are designed to respond with maximum flexibility to the needs of your Tufts Health Public Plans patients and will vary according to those needs over time. CSPs may begin prior to their discharge from a 24-hour level of care, if indicated, and include face-to-face contact in a home or other setting based on clinical needs. CSP providers may help your Tufts Health Public Plans patients: Arrange transportation Participate in treatment team meetings Attend BH or medical appointments Help build community links and supports Provide crisis interventions as needed Some CSP services are nonbillable administrative activities that we factor into your contracted rate, including: Telephone contact with us to request or discuss authorization of services Completion of progress notes or billing documentation Time (in units) spent conducting team meetings, supervising staff, or checking member eligibility Routine transportation; however, you can bill for services you provide to the member (e.g., interventions you can document) for a period of time while in transit Services lasting less than 15 minutes when the appropriate billing code uses 15-minute increments (you can bill with separate dates of service that are less than 15 minutes each, which total 15 minutes combined) While CSPs complement other services already in place for your patients, the community support worker does not provide individual therapy and does not replace the role of your patients existing therapist or PCP. In addition to community referrals, a care manager may refer your Tufts Health Public Plans patients to CSPs. We will evaluate these referrals based on your patients clinical history and current clinical presentation. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

50 CSP level-of-care criteria Admission criteria To receive CSP services, your Tufts Health Public Plans patients must meet the following criteria: They are at risk for hospitalization or multiple hospitalizations, as indicated by: Demonstrating underutilization or noncompliance with recommended community-based services Experiencing a catastrophic event (e.g., loss of a child) Being newly enrolled with Tufts Health Public Plans with a history of multiple BH hospitalizations Being newly diagnosed with a major mental illness Having special needs, such as concurrent medical illness, physical disability, or cultural issues that require multiple agency coordination for service delivery Having a number of Tufts Health Public Plans patients in a single family who utilize intensive services, requiring multiple agency coordination Their ability to make use of other covered services or be stable in the community can improve with CSPs. They are willing to accept CSPs, and/or the parent, guardian, or authorized representative is willing to accept CSPs. Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they have a(n): Organic mental disorder (e.g., delirium, dementia, amnesia) and other cognitive disorders Mental disorder due to a primary medical condition Mental disability Please note: Exclusion criteria apply unless patients have a DSM-IV diagnosis, treatable at this level of care, that is the focus of the intervention. Continued-stay criteria In addition to the criteria listed on page 7, your patients must: Continue to keep appointments and comply with the master treatment plan Experience symptoms of such intensity that, if discharged, would require a more intensive level of care Attempt discharge planning, indicated by your Tufts Health Public Plans patient remaining stable at the highest level of functioning for at least two months Discharge criteria In addition to the criteria listed on page 7, you may also discharge your patients if they: Follow an individualized treatment/care plan and are stable at the highest level of functioning for six months Begin receiving care from a long-term facility Appear to reach the maximum benefit from community support services Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

51 CSP referral procedure Any Tufts Health Public Plans BH provider, state agency staff person, medical provider, or other individual may refer your Tufts Health Public Plans patients to a community support program. CSP authorization procedure We do not require prior authorization for the initial authorization period for in-network CSPs. Providers have up to 60 days and/or 240 units (1 unit = 15 minutes), whichever comes first, to see your Tufts Health Public Plans patients, conduct an initial assessment, and provide services to meet your Tufts Health Public Plans patients needs. To request additional units/time, please call a Tufts Health Public Plans BH care manager at Continued-stay review procedure CSPs may be a short-term-focused intervention or a service your Tufts Health Public Plans patients receive to support community tenure over a longer period. Continuation beyond the original 60-day and/or 240-unit period of the admission requires continued-stay review and approval. Our clinical manager will authorize care for a period of time based on your Tufts Health Public Plans patients situation. The CSP will call our clinical manager at for a continued-stay review prior to the expiration of the initial time and/or units and for any authorization thereafter. We will deny reimbursement for the interval between the last covered day and the date of the next contact if you call us after the initially authorized time frame. Please see the criteria listed on page 8 for the information about your Tufts Health Public Plans patients you should have available to request a continued-stay review. Family stabilization team (FST) for Tufts Health Direct (Qualified Health Plan) members only An FST provides intensive stabilization services for your Tufts Health Public Plans patients and their parent/guardian(s) after a psychiatric episode that requires acute mental health treatment, or as a diversion to prevent an inpatient or Community-based Acute Treatment (CBAT) for children and adolescents admission. The FST provides flexible services, including 24-hour oncall support, to help the parent/guardian(s) reintegrate your Tufts Health Public Plans patients into the family either during an episode of acute mental illness or substance use, or following out-of-home treatment for such an episode. An FST comprises providers trained in family systems, behavioral interventions, and/or psychiatric nursing. The FST will address multiple life stressors to prevent hospitalization, enable your patients to transition successfully and more quickly from a hospital to a less restrictive setting, and prevent rehospitalizations. The FST will also help the family identify issues (such as substance use) and the outpatient service supports needed to secure appropriate treatment and ensure stability. Please note: FSTs do not provide individual or family psychotherapy. FST services do not replace your Tufts Health Public Plans patients existing therapist or PCP. FST level-of-care clinical criteria Admission criteria for an FST as a step-down To receive FST services as a step-down from an acute service, your Tufts Health Public Plans patients must: Be discharged from an inpatient, Partial Hospital Program (PHP) or CBAT program to an appropriate, safe home setting, as determined by the acute care facility Exhibit a potential for new or repeat hospitalizations by a history of repeat hospitalizations or the length and Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

52 intensity of the current treatment episode Need outpatient services provided at an intensified level, together with appropriate services from the Department of Children and Families (DCF) and/or Department of Mental Health (DMH) to meet the family s needs for support and psycho-education during your Tufts Health Public Plans patients transition into the home Need more clinically appropriate services than residential services Not receive similar in-home services from the DMH or DCF Have families who agree to work with the FST Admission criteria for FST direct admissions As appropriate, we may approve an FST request directly after a crisis. Our direct FST admission criteria include the following: There are psychosocial issues in the home environment significantly affecting clinical presentation. Inpatient admission was recent, and behavior has escalated due to noncompliance with aftercare plan or inadequate community supports. FST was successful prior to the current crisis and the team s involvement is likely to stabilize the family. Your Tufts Health Public Plans patients do not meet criteria for hospital or community-based acute treatment, but without addressing the issues causing the stress, it will most likely escalate and eventually require admission. More intensive outpatient services will not meet your Tufts Health Public Plans patients and families needs and the ongoing therapist recommends FST. Residential placement is not a more clinically appropriate treatment and your Tufts Health Public Plans patients are not on a waiting list for residential treatment. The DMH or DCF does not provide your Tufts Health Public Plans patients with in-home family services. The family has the potential to be stabilized. The family agrees to work with the FST on the problems the crisis evaluation identifies. Continued-stay criteria In addition to the criteria listed on page 7, your patients must also attempt discharge planning, indicated by your Tufts Health Public Plans patient remaining stable at the highest level of functioning for at least two months. Discharge criteria In addition to the criteria listed on page 7, we require FST providers to complete a discharge review with us that covers the following information about your Tufts Health Public Plans patients: Mental status and DSM-IV Axes I V diagnosis at discharge Discharge medications Aftercare provisions and service providers Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

53 The number of FST contacts and hours of service provided FST authorization procedure Referrals to an FST may come from inpatient providers during the course of hospitalization, outpatient providers, other community care providers (e.g., a school, DCF, pediatricians), and FST providers. To receive authorization for FST services, please call a Tufts Health Public Plans BH care manager at We will provide prior authorization by phone for an initial period. If your Tufts Health Public Plans patients require additional FST services beyond those initially authorized, you must call a BH care manager to review the proposed treatment for clinical appropriateness and medical necessity. Jointly, you must determine with the FST ongoing treatment goals and number of units based on the Tufts Health Public Plans patients needs. Following our initial FST authorization, we expect a meeting to take place within 24 hours of the evaluation and, to the extent possible, to include the family and any other appropriate supports. Structured Outpatient Addiction Program (SOAP) A SOAP provides short-term, clinically intensive, structured day or evening addiction services for your Tufts Health Public Plans patients. Programming occurs in half- or full-day units, is brief, and primarily utilizes a group-oriented treatment model. Treatment is individualized and may decline in intensity as your Tufts Health Public Plans patients connect with other community supports and/or resume normal daily activities. Providers may use a SOAP as a step-down from a more acute level of care, such as a PHP or acute treatment services (ATS) for substance use (Level 3.7), or to provide treatment beyond what a traditional outpatient setting offers. Providers may use a SOAP as a diversion from a more intensive level of care and to help patients avoid relapse and/or regain sobriety if relapse occurred and patients do not need detoxification. SOAP level-of-care criteria Admission criteria To receive treatment from a SOAP, your Tufts Health Public Plans patients must: Have a DSM-IV primary alcohol/substance-use or dependence diagnosis Be motivated to participate in treatment and at risk of needing a more intensive level of care if not engaged in an intensive outpatient treatment Have adequate psychosocial supports that will provide enough stability to warrant a structured outpatient setting Have an individualized treatment plan with specific goals allowing for transition to a less intensive level of care Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they have a(n): Organic mental disorder (e.g., delirium, dementia, amnesia) and other cognitive disorders Mental disorder due to a primary medical condition Active symptoms of withdrawal Suicidal or homicidal thoughts and inability to maintain safety Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

54 Please note: Exclusion criteria apply unless patients have a DSM-IV diagnosis, treatable at this level of care, that is the focus of the intervention. Continued-stay criteria In addition to the criteria listed on page 7, your patients must also be at risk for relapse, or experience symptoms of such intensity that, if they are not receiving services from a SOAP, would require a more intensive level of care. Discharge criteria There are no additional criteria besides those listed on page 7. SOAP authorization procedure Referrals to a SOAP may come from a less (e.g., outpatient) or more intensive level of care (e.g., inpatient substance use), ATS for substance use (Level III.7), or a PHP. Our authorization process differs depending on where the referral originates. Step-down from 24-hour care SOAP may be an appropriate step-down from an inpatient level of care, observation, or other acute service. In these cases, the 24-hour facility or BH care manager may request and/or suggest your Tufts Health Public Plans patients use a SOAP. We will authorize the treatment as part of the continuing care review. Initial assessment and prior authorization for direct admission The SOAP s clinical intake provider should call a Tufts Health Public Plans BH care manager at for prior authorization when a less intensive level of care requests a SOAP or prior authorization for direct admission. Prior authorization review Please have the following information available about your Tufts Health Public Plans patients when you request authorization: Tufts Health Public Plans member ID number Name, gender, date of birth, and city or town of residence Designated ESP provider name, and date and time of evaluation, if involved A DSM-IV diagnosis (all five axes are appropriate, but we require Axes I and V; we will accept a provisional diagnosis) The precipitating event and/or current symptoms requiring this level of care Recommended treatment plan to address problem(s) Medication history Substance-use history Prior treatment history General medical and psychosocial history (including family) PCP information Continued-stay review procedure Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

55 There are no additional requirements besides those listed on page 9. Psychiatric day treatment Psychiatric day treatment programs focus on maintaining or enhancing your Tufts Health Public Plans patients current levels of functioning and skills in the community. Psychiatric day treatment aims to help your Tufts Health Public Plans patients develop: Additional coping skills Community supports Access to resources These skills will assist with making clinical and social gains when your Tufts Health Public Plans patients no longer need the day treatment program and/or transition to a less intensive level of care (e.g., supported work setting, BH program, psychosocial rehabilitation program). Psychiatric day treatment level-of-care criteria Admission criteria To receive psychiatric day treatment, your Tufts Health Public Plans patients must: Have an active DSM-IV Axis I or II diagnosis, and a level of functioning below their baseline Benefit from both mental health treatment and daily living activities Respond best to day treatment, based on diagnosis or evaluation of present functioning and/or past history, and treatment at a less intense level of care would contribute to an exacerbation of symptoms Have a treatment plan that reflects diagnosis, has specific goals, and allows for gradual transition to less intensive levels of care, as appropriate Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they have a(n): Organic mental disorder (e.g., delirium, dementia, amnesia) and other cognitive disorders Mental disorder due to a primary medical condition Involuntary admission Primary substance-use diagnosis Please note: Exclusion criteria apply unless patients have a DSM-IV diagnosis, treatable at this level of care, that is the focus of the intervention. Continued-stay criteria In addition to the criteria listed on page 7, your patients must: Have an individualized treatment plan, including any psychiatrist s orders, special procedures, and medications Experience symptoms of such intensity that, if discharged, would require a more intensive level of care Show improvement in the program or be at risk for a more acute level of care, if participation in day treatment is terminated Attempt to discharge or move to a lesser level of care Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

56 Discharge criteria There are no additional criteria besides those listed on page 7. Psychiatric day treatment prior authorization procedure Initial day treatment services require authorization, which you can obtain by calling a BH care manager at We will authorize an initial length of stay based on the clinical presentation and clinical/medical necessity of the service. Please have the following information about your Tufts Health Public Plans patients available at the time of the initial review: Tufts Health Public Plans member ID number Name, gender, date of birth, and city or town of residence Provider/facility name and requested length of stay DSM-IV diagnosis (all five axes as appropriate, but we require Axes I and V; we will accept a provisional diagnosis) Recommended initial treatment plan (and goals) Medication history Substance-use history Rationale for this level of care Continued-stay review procedure There are no additional requirements besides those listed on page 9. Intensive outpatient program (IOP) An IOP is a short-term day or evening program available to your Tufts Health Public Plans patients who experience an acute exacerbation of psychiatric symptoms or psychosocial stressors, are at risk for relapse, and are unable to be safely treated in a less intense setting. A hospital-based or freestanding facility may provide an IOP to your Tufts Health Public Plans patients at risk for further decompensation or who are stepping down from a more intensive level of care and for whom a lesser level of care would be insufficient. IOP level-of-care criteria Admission criteria To receive treatment from an IOP, your Tufts Health Public Plans patients must: Have an active DSM-IV Axis I or II diagnosis Be motivated to participate in treatment and at risk for needing a more intensive level of care if not engaged in intensive outpatient treatment services Have a documented history of some success in an intensive outpatient setting (e.g., a PHP, crisis stabilization visits) Have a living environment that, however compromised, offers enough psychosocial stability (i.e., an environment with one or more supportive others) to warrant intensive outpatient treatment Have an individualized treatment plan with specific goals allowing for a transition to less intensive treatment Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

57 Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they have a(n): Organic mental disorder (e.g., delirium, dementia, amnesia) and other cognitive disorders Mental disorder due to a primary medical condition Primary substance-use diagnosis Please note: Exclusion criteria apply unless patients have a DSM-IV diagnosis, treatable at this level of care, that is the focus of the intervention. Continued-stay criteria In addition to the criteria listed on page 7, your patients must: Have an individualized treatment plan, including any psychiatrist s orders, special procedures, and medications Experience symptoms of such intensity that, if discharged, would require a more intensive level of care Discharge criteria There are no additional criteria besides those listed on page 7. IOP authorization procedure Referrals for IOP may come from a less (e.g., outpatient, day treatment) or more intensive level of care (e.g., PHP, inpatient mental health). Our service authorization procedure will differ depending on where the referral originates. Step-down from 24-hour care IOP may be an appropriate step-down from a more intensive level of care. In this case, the 24-hour facility or our BH care manager may request and/or suggest using an IOP. We will conduct the authorization process as part of the continuing care review. Once we approve transitioning to an IOP, the 24-hour treating facility will refer your Tufts Health Public Plans patients to the most appropriate IOP at discharge from the 24-hour level of care. Initial assessment and prior authorization required for direct admission The IOP clinician or a treating provider must call a Tufts Health Public Plans BH care manager at for prior authorization when a provider at a less intensive level of care requests IOP services or asks for prior authorization for direct admission. A designated ESP provider may also be involved in the authorization process for Tufts Health Public Plans members. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

58 Prior authorization review Please have the following information about your Tufts Health Public Plans patients available when requesting prior authorization: Tufts Health Public Plans member ID number Name, gender, date of birth, and city or town of residence Designated ESP provider name, and time and date of evaluation, if involved DSM-IV diagnosis (all five axes are appropriate, but we require Axes I and V; we will accept a provisional diagnosis) Precipitating event and/or current symptoms requiring the requested acute level of care Initial recommended treatment plan to address presenting problems Medication history Substance-use history Prior hospitalizations and psychiatric and/or substance-use treatment General medical and psychosocial history (including family) PCP contact information Continued-stay review procedure There are no additional requirements besides those listed on page 8. Partial Hospital Program (PHP) A PHP offers short-term, intensive, acute treatment within a stable therapeutic setting. Hospital-based or freestanding facilities may provide a PHP to your Tufts Health Public Plans patients who are severely ill, disabled, at severe risk for relapse, or for whom a less intensive setting would not work and necessitate an inpatient facility s protection and containment. PHP services are the same level of intensity as hospital-level care for your Tufts Health Public Plans patients with a supportive environment to return to in the evening. You should make a PHP available to provide transition from an inpatient level of care and to continue treatment interventions started on an inpatient unit. For example, a PHP would be appropriate for patients hospitalized for a manic episode who begin taking medications again. As their mood stabilizes, PHPs can continue to monitor the titration of medication and mental status on an outpatient basis, to precipitate discharge to the community. Your Tufts Health Public Plans patients would continue to receive acute care under medical supervision but in a less restrictive environment, including a minimum of twice weekly face-toface meetings with the program s psychiatrist/registered nurse clinical specialist. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

59 PHP level-of-care criteria Admission criteria To receive treatment from a PHP, your Tufts Health Public Plans patients must: Manifest significant or profound impairment in daily functioning by virtue of psychiatric illness Exhibit adequate behavior control, not be immediately dangerous to themselves or others, and not require 24-hour medical supervision Exhibit suicidal ideas or gestures, a history of self-mutilation or self-endangering behaviors, and tendencies to assault others Have an acuity that falls short of inpatient criteria Have a community-based network of support that assists in maintaining them within the least restrictive environment Have the capacity for reliable attendance and active participation in all PHP phases Have presenting symptoms so severe that a less intensive or outpatient setting could not provide safe or adequate treatment Be ready for discharge from an inpatient setting but judged to need daily monitoring, support, and ongoing therapeutic intervention for a time of stabilization Have the parent, guardian, or authorized representative consent to treatment for children and adolescents Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they have a(n): Organic mental disorder (e.g., delirium, dementia, amnesia) and other cognitive disorders Mental disorder due to a primary medical condition Please note: Exclusion criteria apply unless patients have a DSM-IV diagnosis, treatable at this level of care, that is the focus of the intervention. Continued-stay criteria In addition to the criteria listed on page 7, your patients must: Have an individualized treatment plan, including any psychiatrist s orders, special procedures, and medications Experience symptoms of such intensity that, if discharged, would require a more intensive level of care Discharge criteria In addition to the criteria for your patients listed on page 7, you must conduct a telephonic discharge review with a BH care manager within one business day of discharge. Please call us at to conduct this review and have the following information available: Status upon discharge Diagnosis at discharge Medications upon discharge Aftercare plan Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

60 PHP authorization procedure A less (e.g., outpatient, day treatment) or more intensive level of care (e.g., inpatient psychiatric) may refer your Tufts Health Public Plans patients to a PHP. Our service authorization procedure will differ depending on where the referral originates. Step-down from 24-hour care When a PHP is used as a step-down from a more intensive level of care, the 24-hour facility must conduct the authorization process as part of the continuing care review. Once we approve the transition to a PHP, the 24-hour treating facility will refer your Tufts Health Public Plans patients to the most appropriate PHP. For many hospitals, this will generally be a transition within their own facility but you may want to take into account geographic and/or clinical concerns when determining the appropriateness of a program choice. Initial assessment and prior authorization required for direct admission When a provider requests PHP authorization for a patient receiving a less intensive level of care, or the provider requests direct admission, the PHP s clinical intake provider or a treating provider must call a Tufts Health Public Plans BH care manager at for prior authorization. A designated ESP provider may also be involved in the referral process for Tufts Health Public Plans members. Prior authorization review Please have the following information about your Tufts Health Public Plans patients available when requesting prior authorization: Tufts Health Public Plans member ID number Name, gender, date of birth, and city or town of residence ESP provider name, and time and date of evaluation, if involved DSM-IV diagnosis (all five axes are appropriate, but we require Axes I and V; we will accept a provisional diagnosis) Precipitating event and/or current symptoms requiring the requested acute level of care Initial recommended treatment plan to address presenting problem(s) Medication history Substance-use history Prior hospitalizations and psychiatric and/or substance-use treatment General medical and psychosocial history PCP information Continued-stay review procedure There are no additional requirements besides those listed on page 8. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

61 24-HOUR DIVERSIONARY SERVICES We also offer 24-hour diversionary services to help your patients transition between levels of care, or to divert the need for inpatient hospitalization. Community-based Acute Treatment (CBAT) for children and adolescents CBAT is a 24-hour therapeutically planned group living program that also provides individualized therapeutic treatment. CBAT is not equivalent to acute, intermediate, or long-term hospital care; rather, it is a less restrictive environment that allows for stabilization as an alternative to inpatient care or to further stabilization and integration following an acute stay. A CBAT program must be both physically and programmatically distinct if part of a larger treatment program. A CBAT program serves your Tufts Health Public Plans patients who have sufficient potential to respond to active treatment, who need a protected and structured environment, and for whom outpatient or partial hospitalization is not adequate and acute hospital inpatient treatment is not necessary. During treatment, your Tufts Health Public Plans patients and their families should participate in treatment as appropriate. All children and adolescents enrolled in a CBAT program must have parent/guardian consent. The CBAT program must comply with all requirements relating to restraint and seclusion as set forth in 42 CFR subpart D, and 42 CFR 483 subpart G. A CBAT program provides consultations, psychological testing, and routine medical care when appropriate, which is included in the per diem rate for acute residential treatment. You must report any medical services that extend beyond routine care to Tufts Health Public Plans for benefit coordination. CBAT level-of-care criteria Admission criteria To receive care from a CBAT program, your Tufts Health Public Plans patients must: Have a DSM-IV Axis I or II diagnosis Experience mood and/or thought or behavior disorders of such severity as to endanger themselves or others if treated at a less restrictive level of care Have sufficient intellectual capacity to respond to active psychological treatment Have family/guardian(s) participating in treatment where appropriate, with documentation around coordination of treatment and with state agencies, if involved Develop an active treatment plan addressing symptomatic and dysfunctional behaviors, providing individualized interventions aimed at reducing or targeting those behaviors, and with specific discharge criteria Have behaviors or symptoms, as evidenced by the initial assessment and plan of care, likely to respond to or already responding to active treatment Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

62 Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they have a(n): Organic mental disorder (e.g., delirium, dementia, amnesia) and other cognitive disorders Mental disorder due to a primary medical condition Involuntary admission Primary substance-use diagnosis Please note: Exclusion criteria apply unless patients have a DSM-IV diagnosis, treatable at this level of care, that is the focus of the intervention. Continued-stay criteria In addition to the criteria listed on page 7, your patients must also attempt to discharge or move to a lesser level of care. Discharge criteria In addition to the criteria for your patients listed on page 7, you must conduct a telephonic discharge review with a BH care manager within one business day of discharge. Please call us at to conduct this review and have the following information available: Status upon discharge Diagnosis at discharge Medications upon discharge Aftercare plan CBAT authorization procedure Referrals for CBAT may come from a less (e.g., outpatient, day treatment) or more intensive level of care (e.g., inpatient psychiatric). Our service authorization procedure differs depending on where the referral originates. Step-down from 24-hour care When a more intensive level of care requests CBAT program services, the 24-hour facility must conduct the prior authorization process as part of the continuing-care review. Initial assessment and notification required for direct admission The referring provider must refer Tufts Health Public Plans patients to a designated ESP provider for an assessment when a less intensive level of care requests CBAT program services. We require the ESP and the admitting facility to notify us of urgent behavioral health admissions within one business day of the admission. We require the ESP provider to fax us the ESP assessment to and include relevant clinical information and disposition within one business day of the encounter. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

63 Notification procedure and authorization review Please have the following information available about your Tufts Health Public Plans patients when notifying us of an urgent behavioral health admission and when requesting prior authorization for a step-down from 24-hour care: Tufts Health Public Plans member ID number Name, gender, date of birth, and city or town or residence DSM-IV diagnosis (all five axes as appropriate, but we require Axes I and V) Precipitating event/current symptoms requiring this level of care Description of the recommended treatment plan relating to the admitting symptoms Medication history Substance-use history Prior treatment history General medical and psychosocial history (including family) PCP information Continued-stay review procedure There are no additional requirements besides those listed on page 8. Dual Diagnosis Acute Residential Treatment (DDART) DDART provides a 24-hour therapeutically planned group-living program for your Tufts Health Public Plans patients with both mental health and substance-use diagnoses. Additionally, the program provides individualized therapeutic treatment and treatment planning. DDART must be both physically and programmatically distinct if part of a larger treatment program. Your Tufts Health Public Plans patients who have sufficient potential to respond to active treatment, who need a protected and structured environment, and for whom a lesser or more intensive level of care is not appropriate may benefit from this level of care. DDART level-of-care criteria Admission criteria To receive DDART, your Tufts Health Public Plans patients must: Have a DSM-IV Axis I diagnosis for both psychiatric and substance-use/dependence conditions Have psychiatric and substance-use/dependence conditions that require 24-hour medical and/or psychiatric and nursing services Agree to a voluntary placement and be able to contract for safety Develop an active treatment plan that addresses symptomatic and dysfunctional behaviors, provides individualized interventions aimed at reducing or targeting those behaviors, and has specific discharge criteria Have behaviors or symptoms, as evidenced in the initial assessment, likely to respond to active treatment Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

64 Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they have: An organic mental disorder (e.g., delirium, dementia, amnesia) and other cognitive disorders A mental disorder due to a primary medical condition Active symptoms of detoxification, or signs of withdrawal Active suicidal and/or homicidal thoughts Please note: Exclusion criteria apply unless patients have a DSM-IV diagnosis, treatable at this level of care, that is the focus of the intervention. Continued-stay criteria In addition to the criteria listed on page 7, your patients must also attempt to discharge or move to a lesser level of care. Discharge criteria In addition to the criteria for your patients listed on page 7, you must conduct a telephonic discharge review with a BH care manager within one business day of discharge. Please call us at to conduct this review and have the following information available: Status upon discharge Diagnosis at discharge Medications upon discharge Aftercare plan DDART referral procedure Referrals for DDART may come from a less (e.g., outpatient, day treatment) or more intensive level of care (e.g., inpatient psychiatric, inpatient substance-use service). Our procedure for service authorization will differ depending on where the referral originates. See the appropriate service for prior authorization procedures. DDART notification procedure The referring provider must refer Tufts Health Public Plans patients to a designated ESP provider for an assessment when a less intensive level of care requests DDART. We require the ESP and the admitting facility to notify us of urgent behavioral health admissions within one business day of the admission. We require the ESP provider to fax us the ESP assessment to and include relevant clinical information and disposition within one business day of the encounter. Step-down from 24-hour care The 24-hour facility must conduct the prior authorization process as part of the continuing care review when a more intensive level of care requests DDART. Continued-stay review procedure There are no additional requirements besides those listed on page 8. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

65 Enhanced Acute Treatment Services (EATS) EATS are for your Tufts Health Public Plans patients with co-occurring addiction and mental health disorders that both require a 24-hour level of care. EATS patients require both detoxification services by an inpatient, 24-hour, medically monitored evaluation, care, and treatment facility, as well as 24-hour care and treatment for their mental health needs, including thorough psychopharmacologic evaluation and treatment for stabilization. We expect a licensed acute-care or community-based setting (e.g., licensed freestanding or hospital-based program, licensed detoxification program) to deliver EATS with 24-hour provider- and psychiatrist-consultation availability, 24-hour nursing care and observation, counseling staff trained in addiction and mental health treatment, and overall monitoring of medical care. EATS level-of-care criteria Admission criteria To receive EATS, your Tufts Health Public Plans patients must: Be 19 years of age or older Be voluntarily admitted Have symptoms consistent with DSM-IV diagnosis (Axes I-V), mental health and substance-use/dependence Require and be responsive to intensive, structured intervention Have a history of psychiatric issues requiring treatment Be at risk of developing withdrawal syndrome from alcohol or other drugs Have a history of using cocaine in high doses, be within seven days of such drug use, and have a history of failure at lesser levels of care Have used injectable opiates daily for more than two weeks and have a history of inability to complete withdrawal as an outpatient or without medication in a lower level of care In addition to the above, your Tufts Health Public Plans patients must have at least one of the following: Suicidal ideation, or a history of suicidal ideation, possibly related to recent substance use, but no actionable plan, and can be safely maintained in a highly structured, 24-hour therapeutic setting Sufficient intellectual capacity to respond to active psychological and rehabilitation treatment A need for inpatient hospitalization without access to these services Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they have: A psychiatric condition of such severity that safe maintenance can only occur in a locked inpatient psychiatric level of care Active signs of assaultive behavior requiring chemical or physical restraint An unwillingness to voluntarily sign in for admission Active suicidal thoughts and an actionable plan that cannot be safely maintained at this level of care Unstable medical conditions and treatment needs that a less intensive level of care will not meet Please note: Exclusion criteria apply unless patients have a DSM-IV diagnosis, treatable at this level of care, that is the focus of the intervention. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

66 Continued-stay criteria In addition to the criteria listed on page 7, your patients must also have provider documentation, when medically appropriate, of pharmacological intervention and its progress/effects. Discharge criteria In addition to the criteria listed on page 7, you may also discharge your patients if they appear not to be participating in the treatment plan or making progress toward goals to such a degree that treatment at this level of care is ineffective or unsafe, despite multiple documented attempts to address noncompliance issues. Also, you must conduct telephonic discharge reviews with a BH care manager within one business day of discharge. Please call us at to conduct this review and have the following information available: Status upon discharge Diagnosis at discharge Medications upon discharge Aftercare plan EATS notification procedure To refer your Tufts Health Public Plans patients for EATS program services, your Tufts Health Public Plans patients must see a designated ESP provider for an assessment. We require the ESP and the admitting facility to notify us of urgent behavioral health admissions within one business day of the admission. We require the ESP provider to fax us the ESP assessment to and include relevant clinical information and disposition within one business day of the encounter. Prior authorization review Please have the following information about your Tufts Health Public Plans patients available when requesting prior authorization for a step-down from 24-hour care: Tufts Health Public Plans member ID number Name, gender, date of birth, and city or town of residence Name of designated ESP provider, and time and date of evaluation, if involved DSM-IV diagnosis (all five axes are appropriate, but we require Axes I and V; we will accept a provisional diagnosis) Precipitating event and/or current symptoms requiring the acute level of care being requested Initial recommended treatment plan to address presenting problem(s) Medication history Substance-use history Prior hospitalizations and psychiatric and/or substance-use treatment General medical and psychosocial history (including family) PCP information Continued-stay review procedure There are no additional requirements besides those listed on page 8. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

67 Observation Observation allows time for an extended clinical assessment of your Tufts Health Public Plans patients to occur within 24 hours and provide important information about your Tufts Health Public Plans patients condition and treatment needs. The clinical assessment will include, at a minimum: psychiatric, medication, and psychosocial assessments; drug and alcohol assessments; lab work; and physical assessments, as needed. The treatment focuses on providing appropriate psychosocial interventions and/or facilitating referrals to less intensive levels of service. Observation occurs in the context of a hospital setting but must have a separate and distinct care area. Observation level-of-care criteria Admission criteria To receive observation, your Tufts Health Public Plans patients must have: A DSM-IV (Axes I V) diagnosis that requires and is likely to respond to therapeutic interventions Potential to stabilize within 24 hours with or without alternative treatment At least one of the following symptoms: Indication of actual or potential danger to self or others Loss of impulse control leading to life-threatening behavior Substance intoxication with suicidal/homicidal ideation or inability to care for self Acute escalation of psychosocial stresses leading to worsening symptoms and inability to care for self safely in a lesser level of care Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they have a(n): Organic mental disorder (e.g., delirium, dementia, amnesia) and other cognitive disorders Medical disorder due to a primary medical condition Please note: Exclusion criteria apply unless patients have a DSM-IV diagnosis, treatable at this level of care, that is the focus of the intervention. Continued-stay criteria There are no additional criteria besides those listed on page 7. Discharge criteria There are no additional criteria besides those listed on page 7. Observation notification procedure Tufts Health Public Plans requires an initial assessment to determine if your Tufts Health Public Plans patients meet the clinical/medical criteria for observation/holding bed services. A designated ESP provider must evaluate your Tufts Health Public Plans patients. We require the ESP and the admitting facility to notify us of urgent behavioral health admissions within one business day of the admission. We require the ESP provider to fax us the ESP assessment to and include relevant clinical information and disposition within one business day of the encounter. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

68 Notification procedure Please have the following information about your Tufts Health Public Plans patients available when notifying us of an urgent behavioral health admission: Tufts Health Public Plans member ID number Name, gender, date of birth, and city or town of residence Designated ESP provider name, and time and date of evaluation, if involved DSM-IV diagnosis (all five axes are appropriate, but we require Axes I and V; we will accept a provisional diagnosis) Precipitating event and/or current symptoms requiring the requested acute level of care Initial recommended treatment plan to address presenting problem(s) Medication history Substance-use history Prior hospitalizations and psychiatric and/or substance-use treatment General medical and psychosocial history (including family) PCP information Continued-stay review procedure There are no additional requirements besides those listed on page 8. Acute treatment services (ATS) for substance abuse (Level 3.7) ATS for substance-use (Level 3.7) detoxification is located in a licensed acute care setting and provides a planned regimen of 24-hour medically monitored evaluation, care, and treatment for your Tufts Health Public Plans patients with psychoactive substance-use disorders. Provider involvement includes 24-hour consultation availability, daily interaction with your Tufts Health Public Plans patients, and overall medical care monitoring. Your Tufts Health Public Plans patients also receive 24-hour nursing care and observation, and daily counseling by staff trained in addiction treatment. Facilities which provide ATS/PES (Pregnancy Enhanced Services) must offer specific services to meet the needs of pregnant women, including emergency back-up with hospital-based services, nursing staff with obstetrics/gynecology experience and care management. ATS does not require a general hospital s full resources, such as life-support equipment or psychiatric services. Your Tufts Health Public Plans patients who require this level of care often are at risk for severe withdrawal symptoms, do not require the medical and clinical intensity of a hospital-based acute detoxification service, and would not receive effective treatment from a less intensive level of care. Emergency services are available through a contractual arrangement with an acute care hospital. ATS for substance abuse level-of-care criteria Admission criteria To receive ATS, your Tufts Health Public Plans patients must: Have a DSM-IV Axis I diagnosis of substance use or dependence with the risk of complicated withdrawal if detoxification does not include medical supervision Require 24-hour nursing service Meet Interqual initial review criteria for intoxification/withdrawal including physiological evidence of intoxification or withdrawal Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

69 Exclusion criteria Your Tufts Health Public Plans patients who have any of the following are excluded from the admission criteria above: Unless pregnant, have not consistently used substances in the last seven days or demonstrated any signs or symptoms of withdrawal Unless pregnant, have a type of addictive substance or pattern of drug or alcohol usage that will not cause sufficient withdrawal symptoms to require inpatient detoxification Be at risk of developing a moderate-to-severe withdrawal syndrome that is sufficiently complicated to require detoxification at a higher level of care in an inpatient hospital Have a medical condition severe enough to require an acute inpatient hospital setting (inpatient substance-use treatment) Have a condition that requires acute inpatient medical or psychiatric treatment Continued-stay criteria Besides the criteria listed on page 7, your patients must also use medications more than once every 24 hours to modify withdrawal symptoms and irregular vital signs. They must experience symptoms of such intensity that, if discharged, would require a more intensive level of care. Your pregnant patients must continue to need care coordination and aftercare planning in order to safely transition to the next level of care and/or return to the community. Discharge criteria In addition to the criteria for your patients listed on page 7, you must fax us at within one business day of discharge with discharge summary information. Please provide the following information about your patients in the summary: Status upon discharge Diagnosis at discharge Medications upon discharge Aftercare plan with linkages to outpatient providers (e.g., behavioral health, primary care, obstetrics/gynecology, etc.) and community resources ATS initial authorization procedure We require an Acute Treatment Services (ATS) for Substance Abuse Admission Notification Form within one business day of your Tufts Health Public Plans patients admission for ATS for substance abuse (Level 3.7). Notification covers five days of ATS for substance abuse. Please note: Failure to submit the form within one business day may affect your claims payment(s). Continued-stay review procedure There are no additional requirements besides those listed on page 8. Clinical stabilization services (CSS) (Level 3.5) CSS (Level 3.5) are available either as a step-down service from a more intensive level of care, or as a direct referral or admission. We consider CSS 24-hour, structured, therapeutic, short-term residential services that include counseling, education, milieu management, and successful referral to the next level of treatment. CSS attempt to stabilize patients in early recovery and increase treatment retention. Your Tufts Health Public Plans patients who complete medical detoxification, and those who do not meet medical detoxification criteria but have serious substance-use disorders, can use these services. Individuals appropriate for this level of care need intensive early recovery services and support to successfully transition to the appropriate next step in the substance-use treatment continuum. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

70 We expect a CSS length of stay to be less than 30 days. The goal is to provide the necessary interventions and supports to enable your Tufts Health Public Plans patients to engage in the recovery process and plan the services needed to successfully transition to the next level of substance-use treatment as indicated by their assessment. CSS are gender-specific, developmentally appropriate, trauma-informed, and provided with competencies in culture, language, disability, and sexual orientation. CSS level-of-care criteria Admission criteria The appropriate candidate for CSS meets American Society of Addiction Medicines (ASAM) clinical criteria in dimensions 1 6 for admission to a Level 3.5 facility. Your Tufts Health Public Plans patients must have significant social and psychological problems. They may come to the step-down program from a variety of referral sources, including an ATS detoxification program, a physician/hospital/emergency room, a less intensive community-based outpatient or residential substance-use treatment program, or a self-referral. To receive CSS, your Tufts Health Public Plans patients must: Have a DSM-IV diagnosis of substance use or dependence Have a documented history of failed attempts to be substance-free Have inadequate support systems to manage craving intensity Demonstrate a willingness to attempt to live a drug-free life Have an individualized treatment plan Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they have: An organic mental disorder (e.g., delirium, dementia, amnesia) and other cognitive disorders A mental disorder due to a primary medical condition Active symptoms of detoxification and withdrawal Active suicidal and/or homicidal thoughts Please note: Exclusion criteria apply unless patients have a DSM-IV diagnosis, treatable at this level of care, that is the focus of the intervention. Continued-stay criteria In addition to the criteria listed on page 7, your patients must: Experience cravings and symptoms of such intensity that, if discharged, would relapse and/or require a more intensive level of care Need to use medications more than once every 24 hours to modify withdrawal symptoms and irregular vital signs Discharge criteria There are no additional criteria besides those listed on page 7. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

71 CSS referral and authorization procedures Your Tufts Health Public Plans patients may self-refer to CSS, or a more intensive level of care (e.g., ATS for substance abuse, inpatient substance-use service) may refer your patients to CSS. In either case, you must perform an assessment to determine if your patients meet the admission criteria for this level of care. If your patients meet the criteria, you will need to complete a comprehensive assessment and develop an initial treatment plan. If your patients do not meet the criteria, you may refer the patients to a more appropriate level of care, or call us for assistance. We maintain after-hours clinical coverage, which we encourage you to use for further information. We do not require prior authorization for up to 10 days of CSS for substance use (Level 3.5). Should your Tufts Health Public Plans patients require these services beyond 10 days, you will need to call us at prior to the end of the initial 10-day period to request authorization of continued services. Continued-stay review procedure If your Tufts Health Public Plans patients need CSS beyond 10 days, please refer to the continued-stay criteria listed on page 8. Transitional care units (TCU) for Tufts Health Together (MassHealth) members only TCU are designed for patients under age 18 who are in the care or custody of the DCF and: Are not awaiting DCF or other state-funded residential care Can expect to be placed in a: Home setting with parent(s)/caregiver(s) Foster care or community-based group home setting No longer meet medical necessity criteria for continued stay at an inpatient or intensive community-based acute treatment or community-based acute treatment (ICBAT/CBAT) level of care TCU provide an environment that is less restrictive than inpatient and ICBAT/CBAT and more structured than partial hospitalization or outpatient treatment. TCU serve to meet the needs of patients who are ready to leave an acute inpatient setting or ICBAT/CBAT setting, and give priority to patients in inpatient settings. TCU services facilitate your patients transitions to the next placement setting through comprehensive transition planning and medically necessary behavioral health services. TCU level-of-care criteria Admission criteria To receive TCU services, your patients must: Be in the care or custody of the DCF and not need placement in a residential school No longer meet the medical necessity criteria for continued stay at an inpatient level of care Expect to be placed in a: Home setting with parent(s)/caregiver(s) Foster care or community-based group home setting Receive consent for TCU services from the DCF Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

72 Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they: Are at imminent risk to harm self or others, or have sufficient impairment that they require a more intensive level of care Have complex medical or developmental conditions that would preclude beneficial utilization of services Expect to be placed in a residential treatment program Continued-stay criteria In addition to the criteria listed on page 7, your patients must: Remain in care or custody of DCF, and a specific placement resource has not been identified Continue to have medically necessary therapeutic needs Discharge criteria In addition to the criteria listed on page 7, you may also discharge your patients if they: Have substantially met the goals and objectives for TCU services Have an appropriate placement setting and transitional services in place Have planned placement in a residential school or other residential setting Have therapeutic needs that can be met in a less restrictive level of care Also, you must conduct telephonic discharge reviews with a BH care manager within one business day of discharge. Please call us at to conduct this review, and have the following information available: Status upon discharge Diagnosis at discharge Medications upon discharge Aftercare plan INPATIENT SERVICES Inpatient substance abuse services (Level 4.0 detoxification) Inpatient substance abuse services include 24-hour medically directed evaluation, care (including nursing care, counseling, and daily provider visits), and treatment of psychoactive substance-use disorders for your Tufts Health Public Plans patients in a medically managed inpatient setting. A multidisciplinary team of addiction professionals, including addiction-certified clinicians, provide treatment services that allow for the combined treatment of coexisting acute biomedical, emotional, and/or behavioral conditions. Your Tufts Health Public Plans patients receiving such services have access to the full resources of a general hospital, including life-support care and psychiatric treatment. Inpatient substance abuse services are the most intensive level of care provided for detoxification. For your Tufts Health Public Plans patients to receive this level of care, they must require the medical intensity offered in a hospital setting but would not receive adequate treatment in a less intensive level of care. Tufts Health Public Plans models its clinical criteria after American Society of Addiction Medicine (ASAM) guidelines. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

73 If your Tufts Health Public Plans patients do not meet inpatient substance abuse treatment admission criteria, the assessing facility may recommend acute treatment services (ATS) for substance abuse (Level 3.7). Inpatient substance abuse services level-of-care criteria Admission criteria To receive inpatient substance abuse services, your Tufts Health Public Plans patients must: Have a DSM-IV diagnosis of substance use or dependence with evidence of severe risk for withdrawal symptoms (a CIWA-A score greater than or equal to 20) Have a concomitant medical issue requiring medical management because of the intensity of medical and nursing care Have a history of substance use that would result in life-threatening withdrawal without medical management Have ingested sedative-hypnotics daily for at least six months, whether in combination with daily alcohol use or regular use of another mind-altering drug known to pose a severe withdrawal syndrome, and have an accompanying acute mental or physical disorder complicating withdrawal Experience signs and symptoms of severe withdrawal, or show signs of imminent severe withdrawal If your Tufts Health Public Plans patients use alcohol and sedative-hypnotics, they must also: Experience seizures, severe or persistent hallucinations, and/or have a history of DTs If your Tufts Health Public Plans patients use alcohol, they must also: Have an underlying medical or psychiatric comorbid condition that withdrawal symptoms will significantly exacerbate If your Tufts Health Public Plans patients use opiates, they must also: Experience severe opiate withdrawal that a less intensive level of care has not stabilized or managed Use antagonist medication for rapid withdrawal If your Tufts Health Public Plans patients use stimulants, they must also: Have withdrawal signs/symptoms that require psychiatric or medical monitoring more frequently than hourly Exclusion criteria We recommend a different level of care for your Tufts Health Public Plans patients if they have a: Medical condition that does not require active medically managed treatment Type of addictive substance or pattern of drug/alcohol use that will not cause sufficient withdrawal symptoms to require inpatient detoxification Lack of regular, ongoing drug/alcohol use for at least seven days and have not demonstrated signs or symptoms of significant withdrawal Continued-stay criteria In addition to the criteria listed on page 7, your patients must: Experience cravings of such intensity that, if discharged, would relapse and/or require a more intensive level of care Need to use medications more than once every 24 hours to modify withdrawal symptoms and irregular vital signs Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

74 Discharge criteria There are no additional criteria besides those listed on page 7. Inpatient substance abuse services authorization procedure A designated ESP provider must evaluate your Tufts Health Public Plans patients. We require the ESP provider and the admitting facility to notify us of urgent behavioral health admissions within one business day of the admission. We require the ESP provider to fax us the ESP assessment at and include relevant clinical information and disposition within one business day of the admission. Notification procedure Please have the following information about your Tufts Health Public Plans patients available when notifying us of an urgent behavioral health admission: Tufts Health Public Plans member ID number Name, gender, date of birth, and city or town of residence Designated ESP provider name, and time and date of evaluation, if involved DSM-IV diagnosis (all five axes are appropriate, but we require Axes I and V; we will accept a provisional diagnosis) Precipitating event and/or current symptoms requiring this level of care Initial recommended treatment plan to address presenting problem(s) Medication history Substance-use history Prior hospitalizations and psychiatric and/or substance use treatment General medical and psychosocial history (including family) PCP information Continued-stay review procedure There are no additional requirements besides those listed on page 8. Inpatient psychiatric services Your Tufts Health Public Plans patients with an acute psychiatric condition or an acute exacerbation of a chronic condition with a sudden onset or worsening of symptoms will receive the most intensive level of care from inpatient psychiatric treatment. We require that all inpatient psychiatric treatment service providers admit and treat all Tufts Health Public Plans patients for whom we determine a clinical/medical necessity, regardless of clinical presentation, as long as a bed is available in an ageappropriate unit. We use inpatient level of care for Tufts Health Public Plans patients only when less intensive or restrictive levels of care cannot safely or effectively treat your Tufts Health Public Plans patients. For all inpatient services, your Tufts Health Public Plans patients must meet clinical/medical necessity criteria. Treatment and discharge planning must begin at the time of admission. We request that you provide a treatment plan within 24 hours of admission. For children and adolescents, you must include the parent/guardian(s) in treatment planning. We include routine medical care in the per diem rate for inpatient treatment, and you must report to us any medical care above and beyond routine care for benefit coordination. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

75 Inpatient psychiatric treatment level-of-care criteria Admission criteria To receive inpatient psychiatric treatment, your Tufts Health Public Plans patients must have: A DSM-IV Axis I or Axis II diagnosis A psychiatric condition that requires 24-hour psychiatric and nursing services, and a condition of such intensity that only an acute inpatient hospital can provide appropriate services and care A psychiatric condition that will significantly improve with inpatient services in an acute care hospital within a reasonable period of time so the patient will no longer need acute short-term 24-hour inpatient psychiatric and nursing services In addition to the above, your Tufts Health Public Plans patients must have one of the following present: Indication of actual or potential danger to self or others by active means or by nature of poor judgment Suicidal ideation with plan and means available Loss of impulse control resulting in life-threatening behavior, significant weight loss within the past three months, or self-mutilation that could lead to permanent disability Indication of actual or potential danger to property as evidenced by documented recent history or threats of violent, dangerous or destructive acts Impairment to the degree that they manifest major disability in social, interpersonal, occupational, and/or educational functioning, and must not respond to treatment and/or management efforts at a less intensive level of care Signs of severe disorders of cognition, memory, or judgment with attendant psychological impairment, and family/community support cannot provide essential care Willingness to sign a Section 10 and 11 unless clinically contraindicated (e.g., for safety) or be committable under a Section 12 In addition to the above, your Tufts Health Public Plans patients must have one of the following additional factors supporting the necessity of inpatient care: History of previous significant suicide attempts History of suicidal ideation accompanied by severely depressed mood, significant losses, and/or continuing intent to harm self or others Command hallucinations Persecutory delusion Documented recent history of violence Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they have a(n): Organic mental disorder (e.g., delirium, dementia, amnesia) and other cognitive disorders Mental disorder due to a primary medical condition Pervasive developmental disorder (e.g., autism, Asperger s disorder, Rett s disorder) Admission used primarily as an alternative to incarceration or for a Chapter 123, SS15 evaluation when a less intensive level of care cannot safely maintain and effectively treat Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

76 Social, economic, or health problem without concurrent major psychiatric disorder meeting criteria for this level of care Please note: Exclusion criteria apply unless patients have a DSM-IV diagnosis, treatable at this level of care, that is the focus of the intervention. Continued-stay criteria Please refer to the criteria listed on page 7. Discharge criteria In addition to the criteria for your patients listed on page 7, you must conduct telephonic discharge reviews with a BH care manager within one business day of discharge. Please call us at to conduct this review and have the following information available: Status upon discharge Diagnosis at discharge Medications upon discharge Aftercare plan Follow-up appointment details* * Our quality standards for making discharge appointments include a: Psychotherapy appointment within seven calendar days of discharge (please note that we require providers to schedule their patients for two outpatient behavioral health visits within seven days of discharge) Psychopharmacology appointment within 14 calendar days of discharge Inpatient psychiatric treatment notification procedure We require an initial assessment to determine if your Tufts Health Public Plans patients meet inpatient level of care clinical criteria. A designated ESP provider may evaluate your Tufts Health Public Plans patients. We require the ESP provider and the admitting facility to notify us of urgent behavioral health admissions within one business day of the admission. We require the ESP provider to fax us the ESP assessment at and include relevant clinical information and disposition within one business day of the admission. Notification procedure Please have the following information about your Tufts Health Public Plans patients available when notifying us of an urgent behavioral health admission: Tufts Health Public Plans member ID number Name, gender, date of birth, and city or town of residence Designated ESP provider name, and time and date of evaluation, if involved DSM-IV diagnosis (all five axes are appropriate, but we require Axes I and V; we will accept a provisional diagnosis) Precipitating event and/or current symptoms requiring the requested acute level of care Initial recommended treatment plan to address presenting problem(s) Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

77 Medication history Substance-use history Prior hospitalizations and psychiatric and/or substance-use treatment General medical and psychosocial history (including family) PCP information Continued-stay review procedure There are no additional requirements besides those listed on page 8. Transfers To transfer your Tufts Health Public Plans patients, they must meet the receiving facility s admission criteria and you must request permission from us prior to the transfer. Without prior authorization, we will not reimburse or consider an appeal for relapsed days. You must notify us of a transfer as soon as possible, and no later than four hours after an emergency admission. We will schedule an admission review at that time. We will deny reimbursement for the interval between admission and the date you request authorization if you call us after the initially authorized time frame. We will complete a postadmission review over the telephone, requesting the same information we need for a prior authorization review. If your Tufts Health Public Plans patients present to an out-of-network hospital with a primary psychiatric diagnosis or a substance-use diagnosis, then a hospital or referring clinician should contact a designated ESP provider to complete an evaluation. We will work with the evaluating clinician to arrange admission to a BH provider s psychiatric unit or to another appropriate BH provider s service. CHILDREN S BEHAVIORAL HEALTH INITIATIVE (CBHI) SERVICES FOR TUFTS HEALTH TOGETHER (MASSHEALTH) MEMBERS ONLY The Executive Office of Health and Human Services (EOHHS) and MassHealth, in response to a lawsuit known as Rosie D. v. Romney, created the Children s Behavioral Health Initiative (CBHI). CBHI requires: Education and outreach to you, your Tufts Health Together (MassHealth) patients, the public, and private and state agency staff who come into contact with MassHealth members about Early Periodic Screening, Diagnosis, and Treatment (EPSDT) services Implementation of standardized BH screening as a part of EPSDT well-child visits Standardized BH assessments for your eligible patients who use BH services An information-technology system to track assessments, treatment planning, and treatment delivery Child and Adolescent Needs and Strengths (CANS) assessments Child and Adolescent Needs and Strengths (CANS) requirements As part of the CBHI, we require our outpatient providers to be CANS-tool-certified and to use the CANS tool as part of an initial BH assessment when conducting outpatient therapy for our MassHealth members under the age of 21. Outpatient providers must complete a CANS assessment for inpatient and outpatient visits and all other CBHI services. The state requires providers to update the CANS assessment through the Virtual Gateway Children s Behavioral Health Initiative (CBHI) Application every 90 days. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

78 Conduct a CANS assessment for the following services: Outpatient therapy (diagnostic evaluations and individual, family, and group therapy) In-home therapy Intensive care coordination Discharge planning for the following 24-hour care services: Psychiatric inpatient hospitalization CBAT Intensive Community-based Acute Treatment (ICBAT) See our CBHI Web page for more information. Intensive care coordination (ICC) for Tufts Health Together (MassHealth CommonHealth and Standard) members only ICC facilitates care planning and coordination of services for your Tufts Health Public Plans patients under the age of 21 with serious emotional disturbance (SED). Care planning is driven by the needs of your Tufts Health Public Plans patients and developed through a wraparound planning process that results in an individualized and flexible plan of care for your Tufts Health Public Plans patients and their families. ICC provides a single point of accountability to ensure that medically necessary services are accessed, coordinated, and delivered in a strength-based, individualized, family/youth-driven, and ethnically, culturally, and linguistically relevant manner. ICC is designed to facilitate a collaborative relationship among your Tufts Health Public Plans patients with SED and their families; it also involves child-serving systems to support the parent/guardian(s) in meeting your Tufts Health Public Plans patients needs. The ICC care planning process ensures that a care coordinator organizes and matches care across providers and child-serving systems to enable your Tufts Health Public Plans patients to be served in their home community. The care coordinator facilitates the development of a care-planning team that utilizes multiple tools, including a strength-based assessment inclusive of CANS (MA version), in conjunction with a comprehensive assessment and other clinical information to organize and guide the development of a treatment/care plan and a risk management/safety plan. Comprised of both formal (e.g., care coordinator, providers, case managers from child-serving state agencies) and natural supports (e.g., family members, neighbors, friends) the care-planning team assists the family in: Identifying goals and developing a treatment/care plan and risk management/safety plan Convening care-planning team meetings Coordinating and communicating with the members of the care-planning team to ensure the implementation of the treatment/care plan Working directly with your Tufts Health Public Plans patients and their families to implement elements of the treatment/care plan Coordinating the delivery of available services Monitoring and reviewing progress toward treatment/care-plan goals and updating the treatment/care plan in concert with the care-planning team Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

79 The provision of ICC services reflects the individualized needs of your Tufts Health Public Plans patients and their families. Changes in the intensity of your Tufts Health Public Plans patients needs over time should not result in a change in care coordinator. Delivery of ICC may require care coordinators to team with family partners. In ICC, the care coordinator and family partner work together with your Tufts Health Public Plans patients and their families while maintaining their discrete functions. The family partner works one-on-one and maintains regular frequent contact with the parent/guardian(s) to provide education and support throughout the care-planning process, attends care-planning team meetings, and may assist the parent/guardian(s) in articulating patients strengths, needs, and goals for ICC to the care coordinator and care-planning team. The family partner educates parents/guardian(s) about how to effectively navigate the child-serving systems for themselves and about the existence of informal/community resources available to them, facilitating access to these resources. ICC level-of-care criteria Admission criteria To receive ICC services, your Tufts Health Public Plans patients must meet the criteria for SED as defined by either Part I or II of the criteria below: Part I Your Tufts Health Public Plans patients currently have or at any time during the past year had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet the diagnostic criteria specified within ICD-10 or DSM-IV-TR (and subsequent revisions) of the American Psychiatric Association with the exception of other V codes, substance use, and developmental disorders, unless these disorders co-occur with another diagnosable disturbance. The identified diagnosable disorder has resulted in functional impairment that substantially interferes with or limits your Tufts Health Public Plans patients role or functioning in family, school, or community activities. Part II Your Tufts Health Public Plans patients exhibit one or more of the following characteristics over a long period of time and to a marked degree that adversely affects educational performance: Inability to learn that cannot be explained by intellectual, sensory, or health factors Inability to build or maintain satisfactory interpersonal relationships with peers and teachers Inappropriate types of behavior or feelings under normal circumstances General pervasive mood of unhappiness or depression Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

80 Tendency to develop physical symptoms or fears associated with personal or school problems The emotional impairment is not solely the result of autism, developmental delay, intellectual impairment, hearing impairment, vision impairment, specific learning disability, traumatic brain injury, speech or language impairment, health impairment, or a combination thereof. In addition to the above, your Tufts Health Public Plans patients must: Need or receive multiple services other than ICC from the same or multiple provider(s) or need or receive services from state agencies, special education, or a combination thereof, and need a care-planning team to coordinate services from multiple providers or state agencies, special education, or a combination thereof Provide consent for participation in ICC, or their parent, guardian, or authorized representative provides consent Please note: For your Tufts Health Public Plans patients in a hospital, skilled-nursing facility, psychiatric residential treatment facility, or other residential-treatment setting who meet the above criteria, admission to ICC may occur no more than 180 days prior to discharge from the above settings. Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they: Do not give consent for participation in ICC, or their parent, guardian, or authorized representative does not give consent Are in a hospital, skilled-nursing facility, psychiatric residential treatment facility, or other treatment setting at the time of referral and are unable to return to a family home environment or community setting with community-based supports Continued-stay criteria Your Tufts Health Public Plans patients must meet the following criteria for a continued stay: Clinical condition(s) continues to warrant ICC services to coordinate involvement with state agencies and special education or multiple service providers. Progress toward treatment/care plan goals is evident and has been documented based upon the objectives defined for each goal, but the goals have not yet been substantially achieved despite sound clinical practice consistent with wraparound and the systems of care principles. Progress has not been made, and the care-planning team has identified and implemented changes and revisions to the treatment/care plan to support the goals of your Tufts Health Public Plans patients and their families. Discharge criteria In addition to the criteria listed on page 7, you may also discharge your patients if they: Are placed in a hospital, skilled nursing facility, psychiatric residential treatment facility or other residential treatment setting, and are unable to return to a family home environment or a community setting with community-based supports Have reached the age of 21 Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

81 Prior authorization procedure Tufts Health Public Plans requires the Community Service Agency (CSA) to fax an ICC Notification form to upon first contact with the family. Upon receipt of this fax, the CSA will be sent an authorization letter for 192 units over 42 days of ICC and Family Support and Training (FS&T) services (units are combined for both services). A telephonic review is not required for the initial ICC authorization. The ICC provider is required to complete the following assessments/activities in the first 28 days of enrollment: CANS assessment Strengths, Needs, and Cultural Discovery Compressive assessment Initial care planning team meeting Intensive care plan Continued-stay review procedure In addition to the requirements listed on page 8, you must also provide: A description of the response to treatment from the child and the family since the initial or last continued-stay review The dates of the most recent CANS assessment, last Care Planning Team meeting (CPT), and last individualized education program (IEP) assessment (if applicable) Proposed course of treatment during the continuation period, including but not limited to scheduled family or collateral meetings, and the anticipated response to treatment Discharge Procedure Tufts Health Public Plans requires that you fax us the Intensive Care Coordination (ICC) Discharge Form to when you discontinue ICC services. Family Support and Training (FS&T) for Tufts Health Together (MassHealth CommonHealth and Standard) members only FS&T is a service for the parent/guardian(s) of your Tufts Health Public Plans patients under the age of 21 in home (including foster and therapeutic-foster homes) and other community settings. FS&T provides a structured, one-to-one, strength-based relationship between a FS&T partner and the parent/guardian(s). The purpose of this service is to resolve or ameliorate your Tufts Health Public Plans patients emotional and behavioral needs by improving the capacity to parent. The goal is also to improve your Tufts Health Public Plans patients functioning as identified in their treatment/care plan and to support them in the community or assist them in returning to the community. Services may include: Education Assistance in navigating child-serving systems (e.g., Department of Children and Families [DCF], education, mental health, juvenile justice) Fostering empowerment, including linkages to peer/parent support and self-help groups Assistance in identifying formal and community resources (e.g., after-school programs, food assistance, summer camps) Support, coaching, and training FS&T is delivered by strength-based, culturally and linguistically appropriate, and qualified paraprofessionals under the supervision of a licensed clinician. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

82 FS&T level-of-care criteria Admission criteria To receive FS&T services, your Tufts Health Public Plans patients must meet the following criteria: There is a comprehensive BH assessment inclusive of the CANS-MA indicating your Tufts Health Public Plans patients clinical condition warrants this service. The parent/guardian(s) requires education, support, coaching, and guidance. The parent/guardian(s) needs more than outpatient services for coaching, support, and education. The parent/guardian(s) gives consent and agrees to participate. There is a goal identified in your Tufts Health Public Plans patients treatment or care plan with objective outcome measures pertaining to the development of the capacity to parent in the home or community. They are in a family home environment or have a current plan to return to parent/guardian(s). They are currently engaged in other services (outpatient, in-home therapy [IHT], or ICC) and the provider or ICC care-planning team determines that FS&T services are needed to facilitate the attainment of a goal or objective identified in the treatment/care plan that addresses specific behavioral objectives or performance goals designed to treat challenging behaviors that interfere with your Tufts Health Public Plans patients successful functioning. They are currently receiving services from a clinical hub (current outpatient therapist, IHT provider, or intensive care coordinator). Exclusion criteria We exclude your Tufts Health Public Plans patients from this level of care if they: Have impairment with no reasonable expectation of progress toward identified treatment goals for this service Have no indication of need for this service to ameliorate or resolve emotional needs or to support them in the community Are in an environment that presents a serious safety risk to the FS&T partner making visits, and if alternative community settings are not likely to ameliorate the risk and no other safe venue is available or appropriate for this service Are placed in a residential treatment setting with no current plans to return to the home setting Are in an independent living situation and are not in the family s home or returning to a family setting Have service needs identified in the treatment/care plan being fully met by similar services from the same or other agency Are not engaged in services from a clinical hub Continued-stay criteria In addition to the criteria listed on page 7, your patients must: Require that the parent or guardian continues to receive support Receive care that is rendered in a clinically appropriate manner and focused on the parent or guardian s needs for support, guidance, and coaching Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

83 Receive services and supports that are structured to achieve goals in the most time-efficient manner possible Demonstrate progress in relation to specific behavior, symptoms, or impairments that the provider can describe in objective terms Demonstrate that goals have not yet been achieved, and the provider has made adjustments in the treatment/care plan to address lack of progress Continue to receive services from a clinical hub Your Tufts Health Public Plans patients involved in ICC must also meet the following criteria: Parent/guardian(s) are actively involved on their team for informal and formal supports. There is evidence of active coordination of care with your Tufts Health Public Plans patients care coordinator and/or other services and state agencies. Discharge criteria You may discharge your Tufts Health Public Plans patients from this level of care based on any of the following criteria: The parent/guardian(s) no longer needs this level of one-to-one support and is actively utilizing other formal and/or informal support networks. Treatment/care plan goals and objectives have been substantially met. The parent/guardian(s) is not engaged in the service. The lack of engagement is of such a degree that this type of support becomes ineffective or unsafe, despite multiple, documented attempts to address engagement issues. Consent for treatment is withdrawn by your Tufts Health Public Plans patients or their parent, guardian, or authorized representative. They are placed in a residential treatment setting with no plan for return to the home setting. They have moved to an independent living situation and are no longer in or returning to the family setting. They have reached the age of 21. They no longer receive services from a clinical hub. Initial authorization procedure The FS&T provider must call Tufts Health Public Plans at to obtain an initial authorization if the clinical hub is not an ICC provider. The clinical hub, however, must have a goal on their treatment plan that indicates the goals for the FS&T provider to work on. Goals must be incorporated into the hub s treatment plan and reflect needs from the most recent CANS assessment. When the FS&T is working in conjunction with an ICC provider, then the ICC must call for the initial authorization. Continued-stay procedure The FS&T provider must call Tufts Health Public Plans at to obtain continuing authorization prior to the last covered date of service if the clinical hub is not an ICC provider. When the FS&T is working in conjunction with an ICC provider, the ICC must call for the continuing authorization. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

84 In-home behavioral services (IHBS) for Tufts Health Together (MassHealth CommonHealth and Standard) members only IHBS are delivered by one or more members of a team consisting of professional and paraprofessional staff, offering a combination of medically necessary behavior management therapy and behavior management monitoring. Phone contact and consultation may be provided as part of the intervention. Behavior management therapy includes: Behavioral assessment (including observing your Tufts Health Public Plans patients behavior, antecedents of behaviors, and identification of motivators) Development of a highly specific behavior plan Supervision and coordination of interventions Training of other interveners to address specific behavioral objectives or performance goals Behavior management therapy is designed to treat challenging behaviors that interfere with your Tufts Health Public Plans patients successful functioning. The behavior management therapist develops specific behavioral objectives and interventions that are designed to diminish, extinguish, or improve specific behaviors related to your Tufts Health Public Plans patients BH condition(s) and that are incorporated into the behavior plan and the risk management/safety plan. Behavior management monitoring includes: Implementing the behavior plan Monitoring your Tufts Health Public Plans patients behavior Reinforcing implementation of the behavior plan by parent/guardian(s) Reporting to the behavior management therapist on implementation of the behavior plan and progress toward behavioral objectives or performance goals IHBS level-of-care criteria Admission Criteria To receive IHBS, your Tufts Health Public Plans patients must: Have a comprehensive behavioral health assessment inclusive of the CANS-MA indicating their clinical condition warrants this service Have not been successful in reducing or eliminating the problem behavior(s) or increasing or maintaining desirable behavior(s) through less intensive behavioral interventions Have a clinical evaluation suggesting their clinical condition, level of functioning, and intensity of need require the establishment of a specific structure, and the establishment of positive behavioral supports to be applied consistently across home and school settings; and warrant this level of care to successfully support them in the home and community Consent to treatment, or consent is obtained from their parent, guardian, or authorized representative Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

85 Be currently engaged in other services (e.g., outpatient, IHT, or ICC) and the provider or care-planning team determine that IHBS are needed to facilitate the attainment of a goal or objective identified in the treatment/care plan that address specific behavioral objectives or performance goals designed to treat challenging behaviors that interfere with the youth s successful functioning. There are certain situations where IHBS is clinically indicated without a hub s involvement. In these circumstances, the IHBS provider must submit directly to us their request for an IHBS hub waiver. Criteria for consideration of an IHBS hub waiver include, but are not limited to the following: youth who are non-verbal, those with no need for additional therapeutic services due to their functionality (they meet the exclusionary medical necessity criteria for IHT, ICC, and/or outpatient services), or youth who have no need for carecoordination. Be engaged in services from a clinical hub unless there is an approved hub waiver by Tufts Health Public Plans Exclusion criteria We exclude your Tufts Health Public Plans patients from IHBS if they: Are in an environment that presents a serious safety risk to the service provider, alternative community settings are not likely to ameliorate the risk, and no other safe venue is available or appropriate for this service Are at imminent risk of harm to self or others, or have sufficient impairment that requires a more intensive level of care beyond a community-based intervention Have medical conditions or impairments that would prevent beneficial utilization of services Have similar services meeting the needs identified in the treatment/care plan Are in a hospital, skilled nursing facility, psychiatric residential treatment facility, or other residential setting at the time of referral and are not ready for discharge to a family home environment or community setting with community-based supports Are not engaged in services from a clinical hub unless there is an approved hub waiver by Tufts Health Public Plans Continued-stay criteria In addition to the criteria listed on page 7, your patients must: Have a clinical condition that continues to warrant IHBS to maintain them in the community and assist them in making progress toward goals established in the behavior plan Participate actively in the treatment/care plan to the extent possible and consistent with condition Have parents, guardians and/or natural supports participating in the treatment as required by the behavior plan, or the provider can document active efforts to involve them Continue to engage in services from a clinical hub unless there is an approved hub waiver by Tufts Health Public Plans Discharge criteria There are no additional criteria besides those listed on page 7. We do not require notification of a discharge from inhome behavioral services. Initial authorization procedure The identified IHBS provider must call Tufts Health Public Plans at to obtain an initial authorization. The IHBS provider must present the treatment plan and goals for IHBS as indicated from the clinical hub if a hub is involved. These goals must be incorporated from the hub s treatment plan and must be identified from the most recent CANS assessment. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

86 Continued authorization procedure The IHBS provider must call Tufts Health Public Plans at to obtain continuing authorization prior to the last covered date of service. The clinical hub may not call to request a continued authorization request. The IHBS provider must include the following information in their request for additional services: Current DSM-IV diagnosis (as indicated in most recent CANS) Date of functional behavioral assessment Date of most recent CANS assessment completed by clinical hub Current medications and prescriber information Current treatment goals as written from clinical hub Progress on current treatment goals since last review Barriers to treatment Action plan/next steps to address current barriers to treatment In-home therapy (IHT) for Tufts Health Together (MassHealth) members only IHT services offer a combination of medically necessary IHT and therapeutic training and support delivered by one or more members of a team consisting of professional and paraprofessional staff. The main focus of IHT is to ameliorate your Tufts Health Public Plans patients mental health issues and strengthen the family structures and supports. IHT services are distinguished from traditional therapy in the following ways: Services are delivered in the home and community. Services include 24/7 urgent response capability on the part of the provider. Frequency and duration of a given session matches need and is not time limited. Scheduling is flexible. Services are expected to include the identification of natural supports and include the coordination of care. IHT is situational, working with your Tufts Health Public Plans patients and their families in their home environment, fostering understanding of the family dynamics, and teaching strategies to address stressors as they arise. IHT fosters a structured, consistent, strength-based therapeutic relationship between a licensed clinician and your Tufts Health Public Plans patients and their families for the purpose of treating BH needs, including improving the family s ability to provide effective support for and promote healthy functioning within the family. Interventions are designed to enhance and improve the family s capacity to improve the youth s functioning in the home and community, and may prevent the need for your Tufts Health Public Plans patients admission to an inpatient hospital, psychiatric residential treatment facility, or other treatment setting. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

87 The IHT team, comprising the qualified practitioner(s), family, and your Tufts Health Public Plans patients, develops a treatment plan and, using established psychotherapeutic techniques and intensive family therapy, works with the entire family or a subset of the family to implement focused structural or strategic interventions and behavioral techniques to: Enhance problem solving, limit setting, risk management/safety planning, and communication Build skills to strengthen the family Advance therapeutic goals, or improve ineffective patterns of interaction Identify and utilize community resources Develop and maintain natural supports for your Tufts Health Public Plans patients and the parent/guardian(s) to promote sustainability of treatment gains Therapeutic training and support (TT&S) is provided by a qualified paraprofessional working under the supervision of a clinician to support implementation of the licensed clinician s treatment plan to assist your Tufts Health Public Plans patients and their families in achieving the goals of that plan. The paraprofessional assists the clinician in implementing the therapeutic objectives of the treatment plan designed to address your Tufts Health Public Plans patients mental health, behavioral, and emotional needs. This service includes teaching patients to understand, direct, interpret, manage, and control feelings and emotional responses to situations, and to assist their families to address their emotional and mental health needs. IHT may be provided in any setting where the youth is naturally located, including but not limited to the home (including foster homes and therapeutic foster homes), schools, child care centers, respite settings, and other community settings. Phone contact and consultation are provided as part of the intervention. IHT level-of-care criteria Admission criteria To receive IHT services, your Tufts Health Public Plans patients must meet the following criteria: There is a comprehensive BH assessment inclusive of the CANS-MA indicating your Tufts Health Public Plans patients clinical condition warrants this service. They are in a family home environment (e.g., foster, adoptive, birth, kinship) and have a parent/guardian(s) who voluntarily agrees to participate in IHT. Outpatient services alone are not or would not likely be sufficient to meet your Tufts Health Public Plans patients and their families needs for clinical intervention/treatment. Required consent is obtained. Exclusion criteria We exclude your Tufts Health Public Plans patients from IHT if they: Are in a hospital, skilled nursing facility, psychiatric residential treatment facility, or other residential treatment setting at the time of referral and are not ready for discharge to a family home environment or community setting with community-based supports Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

88 Have similar services meeting the needs identified in the treatment/care plan Are in an environment that presents a serious safety risk to the service provider, alternative community settings are not likely to ameliorate the risk, and no other safe venue is available or appropriate for this service Are in an independent living situation and are not in the families home or are not returning to a family setting Have medical conditions or impairments that would prevent beneficial utilization of services Continued-stay criteria To continue receiving IHT, your Tufts Health Public Plans patients must meet the following criteria: Their clinical condition continues to warrant IHT services and your Tufts Health Public Plans patients are continuing to progress toward identified, documented treatment plan goal(s). Progress toward treatment/care plan-identified goals is evident and has been documented based upon the objectives defined for each goal, but the goals have not yet been substantially met. Progress has not been made, and the IHT team has identified and implemented changes and revisions to the treatment to support the goals of your Tufts Health Public Plans patients and their families. They are actively participating in the treatment as required by the treatment plan/individual care plan to the extent possible with their condition. The parent/guardian(s) actively participates in the treatment as required by the treatment/care plan. Discharge criteria In addition to the criteria listed on page 7, you may also discharge your patients if they are: Placed in a hospital, skilled nursing facility, psychiatric residential treatment facility, or other residential treatment setting and are not ready for discharge to a family home environment or a community setting with community-based supports Not making progress toward treatment goals, and there is no reasonable expectation of progress at this level of care, nor is this level of care required to prevent worsening of their condition We do not require notification of a discharge from in-home therapy services. Initial authorization procedure The IHT provider must call Tufts Health Public Plans at to obtain an initial authorization. The IHT provider must call for authorization no later than one business day after the first IHT session. The IHT provider must present initial treatment goals during the authorization review. Continued authorization procedure The IHT provider must call Tufts Health Public Plans at to obtain continuing authorization prior to the last covered date of service. An ICC may not call to complete a continuing authorization request. The IHT provider must call for a continuing authorization prior to the last authorized date of service. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

89 Therapeutic mentoring (TM) for Tufts Health Together (MassHealth CommonHealth and Standard) members only TM services are available to your Tufts Health Public Plans patients under the age of 21 in any setting where they reside, such as the home (including foster homes and therapeutic foster homes) and other community settings, such as a school, child care centers, respite settings, and other culturally and linguistically appropriate community settings. TM offers structured, one-to-one, strength-based support services between a therapeutic mentor and your patients for the purpose of addressing daily living, social, and communication needs. TM services include: Supporting, coaching, and training in age-appropriate behaviors Interpersonal communication Functional skill-building, problem-solving and conflict resolution, and relating appropriately to others in recreational and social activities TM services help to ensure your patients success in navigating various social contexts, learning new skills, and making functional progress. The therapeutic mentor offers supervision of these interactions and engages your patients in discussions about strategies for effective handling of peer interactions. TM services must be necessary to achieve goals established in an existing treatment/care plan. Providers must document progress toward meeting the identified goals and report regularly to your patients current providers. TM services support age-appropriate social functioning or ameliorate deficits in your patients age-appropriate social functioning. TM level-of-care criteria Admission criteria To receive TM services, your Tufts Health Public Plans patients must meet all of the following criteria: There is a comprehensive behavioral health assessment inclusive of the CANS-MA indicating your Tufts Health Public Plans patients clinical condition warrants this service. They may be at risk for out-of-home placement as a result of a mental health condition or require support in transitioning back to the home, foster home, or community from a congregate care setting. Outpatient services alone are not sufficient to meet coaching, support, and education needs. Consent for treatment is obtained from your Tufts Health Public Plans patients or parent, guardian, or authorized representative. They are currently engaged in other services (e.g., outpatient services, IHT, or ICC) and the provider or care-planning team determines TM can facilitate the attainment of a goal or objective identified in the treatment/care plan that pertains to the development of communication skills, social skills, and peer relationships. They are engaged in services from a clinical hub. Exclusion criteria We exclude your Tufts Health Public Plans patients from TM services if they: Are displaying a pattern of behavior that may pose an imminent risk of harm to self or others, or sufficient impairment exists that requires a more intensive service beyond community-based intervention Have medical conditions or impairments that would prevent beneficial utilization Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

90 Do not need TM services to achieve an identified treatment goal Only need observation or management during sport/physical activity, school, after-school activities, recreation, or for parental respite Are using similar services that are meeting the needs identified in the treatment/care plan Are placed in a residential treatment setting with no plans for return to the home setting Continued-stay criteria In addition to the criteria listed on page 7, your patients must: Have a clinical condition that warrants continuation of TM services toward treatment goals Receive care in a clinically appropriate manner that focuses on their behavioral and functional outcomes as described in the treatment/care plan Demonstrate progress in relation to specific behavior, symptoms, or impairments, which you can describe in objective terms Have not yet achieved treatment goals, or there is evidence of adjustments in the treatment/care plan to address lack of progress Participate actively in the care plan to the extent possible/consistent with their condition Have parent/guardian(s) who are actively involved as required by the treatment/care plan, as applicable Continue to receive services from a clinical hub Discharge criteria Besides the criteria listed on page 7, you may also discharge your patients if they are: Placed in a hospital, skilled nursing facility, psychiatric residential treatment facility, or other residential treatment setting and are not ready for discharge to a family home environment or a community setting with community-based supports No longer receiving services from a clinical hub We do not require notification of a discharge from TM services. Initial authorization procedure Tufts Health Public Plans requires the therapeutic mentor to fax the Therapeutic Mentoring Services Authorization Request Form to to obtain an initial authorization. A telephonic review may also be required if additional clinical information is needed in order to determine an authorization. The therapeutic mentor provider must present the treatment plan and goals for TM as indicated on the clinical hub s treatment plan. Treatment goals must be measurable and observable. The clinical hub provider must incorporate the goals into the treatment plan and identify patients needs from the most recent CANS assessment. Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

91 Continued authorization procedure The therapeutic mentor must call Tufts Health Public Plans at to obtain continuing authorization prior to the last covered date of service. The clinical hub provider may not call for a continued authorization request. The therapeutic mentor must include the following information in his or her request for additional services: Current DSM-IV diagnosis (as indicated from most recent CANS) Date of most recent CANS assessment completed by clinical hub Current medications and prescriber information Current treatment goals as written from clinical hub Progress on current treatment goals since last review Barriers to treatment Action plan or next steps to address current barriers to treatment 5343B Tufts Health Public Plans Provider Manual CHAPTER 4B: BEHAVIORAL HEALTH

92 CHAPTER 4C: PHARMACY We aim to provide high-quality, cost-effective drug therapy options for our members. Refer to this chapter for information about: Our pharmacy benefit Pharmacy prior authorization Limitations Medicare Part D Specialty pharmacy To meet our members therapeutic needs, we welcome clinician, pharmacist, and ancillary medical provider input on our pharmacy program. Please contact our pharmacy team with any suggestions or comments by calling us at Please see Chapter 9 for specific pharmacy information regarding Tufts Health Unify. Our pharmacy benefit We use a Preferred Drug List (PDL) as our list of covered drugs. If you are a Tufts Health Unify provider, refer to the Tufts Health Unify List of Covered Drugs and our Pharmacy program section of Chapter 9. PREFERRED DRUG LIST Our PDL promotes appropriate and cost-effective prescription outpatient drug products. The PDL applies to medications members receive through retail, specialty, and mail-order pharmacies (if applicable), and does not apply to medications used in direct-care settings. We manage the pharmacy program by evaluating the safety, efficacy and cost-effectiveness of drugs. A Pharmacy & Therapeutics (P&T) Committee, consisting of pharmacists and physicians who represent various clinical specialties, reviews the clinical appropriateness of drugs for inclusion in the formulary and approves the criteria (Pharmacy Medical Necessity Guidelines) for drugs in a pharmacy program, such as prior authorization, step therapy, quantity limitations, designated specialty pharmacy, and designated specialty infusion programs. A Drug Coverage Committee (DCC) is responsible for decision-making, and makes drug coverage and formulary management decisions with consideration to the information provided by the P&T Committee. Tufts Health Public Plans Provider Manual CHAPTER 4C: PHARMACY

93 Each quarter, we announce PDL updates via our online provider newsletter, Provider Update. To find out quickly if we cover a specific drug, you can search our PDL by generic name or brand name to find information about coverage and any limitations (prior authorization, quantity limits, step therapy). You can also download a PDF version of our member PDLs. Tufts Health Together (MassHealth) Tufts Health Direct (Qualified Health Plan) PRESCRIPTION INFORMATION For all of your Tufts Health Public Plans patients you can prescribe: Up to a 30-day supply of most medications when patients fill their prescription at a retail pharmacy Up to a 60-day supply of dextroamphetamine or methylphenidate for the treatment of ADHD or narcolepsy You may prescribe a 90-day supply of maintenance medications for Tufts Health Direct patients when they fill their prescriptions through our mail-order pharmacy, CVS/caremark. OVER-THE-COUNTER DRUG LIST Tufts Health Public Plans covers select over-the-counter (OTC) medications for Tufts Health Together and Tufts Health Direct members. If your Tufts Health Public Plans patient needs a covered OTC medication, please write a prescription for the product so your patient can fill it at a pharmacy and obtain the medication under the pharmacy benefit. Please see our over-the-counter medication coverage information for more details. Tufts Health Public Plans Provider Manual CHAPTER 4C: PHARMACY

94 Pharmacy prior authorization Our P&T Committee approves pharmacy medical necessity guidelines for agents that require prior authorization. REQUESTS FOR PRIOR AUTHORIZATION Some drug products listed in the PDL require prior authorization, as noted. To request a pharmacy prior authorization, please refer to the medical necessity guidelines for that drug and fax the request to us: Fax: Our clinicians review requests and make determinations regarding prior authorizations within two business days of receiving complete medical information. We will either approve or deny your request. We will notify you by telephone or fax within one business day of the decision. If we deny your request because it does not meet our clinical guidelines, we may recommend an alternate therapy. Members may appeal denied requests. Please see Chapter 7 for more information on the appeals process. REQUESTS FOR STEP THERAPY AGENTS Step therapy is an automated form of prior authorization, which uses claims history for approval of a drug at the point of sale. Step therapy programs help encourage the clinically proven use of first-line therapies and are designed so that the most therapeutically appropriate and cost-effective agents are used first, before other treatments may be covered. Step therapy protocols are based on current medical findings, FDA-approved drug labeling, and drug costs. Drugs are placed in a step therapy program when one or more of the following criteria are met: The drug is not considered to be first-line therapy by medically accepted clinical practice guidelines. The drug has a disproportionate cost when compared to other agents used to treat the same disease or medical condition. For drugs listed in the PDL as step therapy agents, pharmacy claims are reviewed electronically to ensure a trial of a first-line drug(s). Members who are currently on drugs that meet the initial step therapy criteria will automatically be able to fill their prescriptions for a step therapy medication. If the member does not meet the initial step therapy criteria, the prescription will deny at the point of sale with a message indicating that prior authorization is required. You may submit prior authorization requests to us using the medical review process for members who do not meet the step therapy criteria at the point of sale or who do not have claims history in our system. Tufts Health Public Plans Provider Manual CHAPTER 4C: PHARMACY

95 REQUESTS FOR NONCOVERED DRUGS We consider any product not in the current PDL to be a new-to-market or noncovered drug. Noncovered Drugs are not covered because there are safe, comparably effective, less expensive alternatives available. In most cases, alternatives are approved by the FDA for the treatments of the particular diagnosis and are widely used and accepted by the medical community to treat the same condition. If you believe there is a medical necessity for a member to continue on a noncovered drug product, a request can be submitted under the medical review process. Limitations EXCLUSIONS We do not cover the following medications as part of the pharmacy benefit: Medications used for cosmetic purposes Medications used for male or female sexual dysfunction for Tufts Health Together members Medications used for weight loss for Tufts Health Together members Contraceptive implants* Experimental and/or investigational drugs Infertility agents for Tufts Health Together members* Immunizations administered or dispensed at a pharmacy, except for: Influenza virus vaccine for members who are at least 18 years old, when administered by a pharmacist between August 1 and April 30 at a participating pharmacy*, and Zostavax vaccine for members 60 years of age and older when the prescription is filled and the medication is administered at a participating pharmacy* Medical supplies* Mifepristone (Mifeprex)* Prescription drugs not approved by the United States Food and Drug Administration (FDA) * May be covered as a nonpharmacy benefit If you or your Tufts Health Public Plans patients have questions about coverage, please call us at GENERIC SUBSTITUTION Consistent with current Massachusetts law, which mandates that individuals receive the generic equivalent of a medication when one is available, Tufts Health Public Plans members who are prescribed a brand-name drug will receive the generic at the pharmacy and will pay the applicable tier copayment for that generic. However, when the prescriber writes a no substitutions prescription for a brand-name drug when generic drugs are available, we will not cover the brand-name drug without a provider-submitted request for the noncovered brand-name drug. If your Tufts Health Public Plans patients need a brand-name drug, please submit a request for medical necessity. Tufts Health Public Plans Provider Manual CHAPTER 4C: PHARMACY

96 Certain drug products where blood-level maintenance is crucial, or with complex pharmacokinetics, dosage forms, or narrow therapeutic efficacy, are not subject to substitution. These products are: Dilantin Neoral oral solution Premarin Prograf Synthroid NEW-TO-MARKET DRUGS We review new drugs for safety and efficacy before we add them to our PDL. We delay the coverage determination of new-to-market (NTM) drug products until the P&T Committee has reviewed them. In the interim, if you believe a member has a medical need for the drug product, a request can be submitted under the medical review process. If you have questions regarding the coverage status of a drug, call us at QUANTITY LIMITS The quantity limitations program restricts the quantity of a drug covered in a given time period. These quantities are based on recognized standards of care, such as FDA recommendations for use. If you believe a member needs a quantity greater than the program limitation, a request can be submitted under the medical review process. Medicare Part D If your Tufts Health Public Plans patients have Medicare prescription drug coverage (Part D), their Part D plan will cover most of their prescription drugs. Even so, we will cover some drugs, such as select OTC drugs. Some co-payment amounts may still apply to these covered drugs. For more information, you or your Tufts Health Public Plans patients can call us at Your Tufts Health Public Plans patients can also find out more about their Medicare prescription drug coverage by calling Medicare at (TTY: ), visiting Medicare s website, or referring to their Medicare and You Handbook. Specialty pharmacy Our goal is to have access to the most clinically appropriate, cost-effective services for our members. We have a designated speciality pharmacy program to supply a select number of medications used to treat complex disease states. Specialty pharmacies specialize in providing these medications and are staffed with nurses, coordinators, and pharmacists to provide support services for members. Medications include, but are not limited to, those used to treat hepatitis C, growth hormone deficiency, infertility, multiple sclerosis, rheumatoid arthritis, and cancers. When appropriate, additional medications are identified and added to this program. Tufts Health Public Plans Provider Manual CHAPTER 4C: PHARMACY

97 We offer members a specialty pharmacy program through CVS/caremark. For most medications, you may prescribe up to a 30-day supply of medication through CVS/caremark. Please use the CVS/caremark Enrollment Form to request specialty medications. You can also see information about our specialty pharmacy program and included medications that CVS/caremark supplies. Medications that CVS/caremark provides for Tufts Health Public Plans patients are not covered through retail pharmacies, other specialty pharmacies, or mail-order pharmacies. In addition to providing specific specialty medications, CVS/caremark will: Deliver medications to your Tufts Health Public Plans patients home, designated delivery address, or clinician s office Provide pharmaceutical expertise and counseling to answer Tufts Health Plan patients and/or clinicians questions and offer medication assistance Offer education and wellness programs that provide clinicians and patients with information, materials, and ongoing support to help patients manage their health conditions and improve medication compliance Provide access to staff pharmacists, available to support your Tufts Health Public Plans patients 24 hours a day, seven days a week Please send prescriptions for specialty medications to CVS/caremark. Your patients should contact CVS/caremark to set up delivery of their specialty medications. CVS/caremark phone: CVS/caremark fax: For specialty pharmacy medications that require prior authorization, please refer to the medical necessity guidelines for that drug on our website and fax the request to us at Every year, from November 1 to March 31, CVS/caremark will supply Synagis for Tufts Health Public Plans patients who meet prior authorization guidelines. We will review requests for Synagis according to the most recent American Academy of Pediatrics guidelines. 5343B Tufts Health Public Plans Provider Manual CHAPTER 4C: PHARMACY

98 CHAPTER 4D: UTILIZATION REVIEW We want to make it as seamless as possible for you to provide services that require prior authorization or review to your Tufts Health Public Plans patients. Refer to this chapter for information about: Prior authorizations When and how to obtain prior authorization How to check a prior authorization request s status Initial determinations Concurrent review and expedited service authorizations Reconsideration Retrospective review policy Hospital admissions and inpatient reviews Outpatient procedures Ancillary and other services Prior authorization denial Medical necessity standards Continuity of care Prior authorizations In most instances, you do not need prior authorization for in-network outpatient care services, except for those listed on page 6, but you will need prior authorization before sending your Tufts Health Public Plans patients to a nonpreferred innetwork provider or to an out-of-network provider. You can use our Find a Doctor, Hospital, or Pharmacy tool to see which providers need prior authorization. You must also get prior authorization for certain surgical day/ambulatory/outpatient procedures (please see the list on page 6). You must submit a Standardized Prior Authorization Request Form at least five business days in advance of the scheduled procedure, service, or planned admission. You do not need prior authorization for: Routine surgical day procedures (i.e., nonexperimental, appropriate for the patient s condition) by a preferred innetwork provider at an in-network facility, except for those listed on page 6 Emergency room and post-stabilization services Apnea monitors Cardiac rehab Electric breast pumps (non-hospital grade) Home health care services less than six months in duration unless the requests is for daily visits Office-based UV light therapy Pulmonary rehab Wigs Tufts Health Public Plans Provider Manual CHAPTER 4D: UTILIZATION REVIEW

99 For all Tufts Health Public Plans members, we review standard prior authorization requests within two business days of getting the information we need to determine medical necessity. However, for Tufts Health Together members, we have up to 14 calendar days to review standard prior authorization requests following the receipt of the request; we can also extend the time frame an additional 14 calendar days if we need further information to make an authorization determination. We will notify you of our authorization decision by letter. You may request an expedited prior authorization using the same form for Tufts Health Public Plans patients who have an urgent health need. Please see Chapter 4B for additional behavioral health services authorization requirements. WHEN AND HOW TO OBTAIN PRIOR AUTHORIZATION You need to get prior authorization for: Referrals to out-of-network providers Certain covered services (e.g., elective inpatient admission, some types of surgery) Nonpreferred in-network facilities, specialists, and providers as identified by our Find a Doctor, Hospital, or Pharmacy tool Daily home health care (HHC) services or for HHC extending beyond six months in duration Certain durable medical equipment (DME) Certain behavioral health services please see Chapter 4B Certain drug authorizations please see Chapter 4C Advanced radiology imaging services (through National Imaging Associates; see our Radiology Imaging Services Payment Policy for more information) Please see the sections listed above for more information about prior authorization time frames and procedures for specific types of services. Providers giving services to Tufts Health Public Plans members may be held accountable if they fail to obtain prior authorization. You can submit a prior authorization request in the following ways: Fax a Standardized Prior Authorization Request Form to us at Directly through Tufts Health Provider Connect HOW TO CHECK A PRIOR AUTHORIZATION REQUEST S STATUS You can check a prior authorization s status: Directly through Tufts Health Provider Connect Through NEHEN or NEHENNet Tufts Health Public Plans Provider Manual CHAPTER 4D: UTILIZATION REVIEW

100 INITIAL DETERMINATIONS We will make an initial determination regarding a proposed admission, procedure, or service requiring prior authorization within two business days of obtaining all the necessary information from you, but no later than 14 calendar days for Tufts Health Together members and no later than four calendar days for Tufts Health Direct members. For Tufts Health Together members, we can also extend the time frame an additional 14 calendar days if we need further information to make an initial determination. If we approve an admission, procedure, facility, or service, we will notify you within 24 hours and send written or electronic confirmation to you and to your patient (if he or she is a Tufts Health Direct member only) within two business days thereafter, stating the service(s) we will cover. Make sure you have this authorization letter before providing any service(s) requiring an authorization. If we make a determination to deny, reduce, modify, or terminate an admission, continued inpatient stay, or any other health care service, we will notify you within 24 hours and send written or electronic confirmation to you and your Tufts Health Public Plans patient within one business day thereafter. We will not pay claims that we receive from out-of-network specialists or nonpreferred in-network providers and/or facilities for any unauthorized services. Our utilization management (UM) staff is available to discuss a denial decision or any other UM issues at , 8 a.m. to 5 p.m., Monday through Friday, excluding holidays, and will also respond to voic s or faxes. If you leave a voic or send a fax during nonbusiness hours, we will respond by the next business day. We base all UM decisions on appropriateness of care, availability of services, and your patients coverage. We do not reward providers, UM clinical staff, or consultants for denying care and do not offer network providers, clinical staff, or consultants money or financial incentives to encourage less use of services. CONCURRENT REVIEW AND EXPEDITED SERVICE AUTHORIZATIONS Concurrent review is utilization review conducted during a member s inpatient hospital stay or course of treatment. Concurrent reviews are typically associated with the extension of previously approved inpatient care, residential behavioral health care, intensive outpatient behavioral health care, and ongoing ambulatory care. We make concurrent review determinations and expedited services authorizations during your Tufts Health Public Plans patients course of treatment within one business day of your request to extend the services beyond the last authorized date. We will notify you of our review decision within one business day and send written or electronic confirmation to you within one business day thereafter. We will notify your patients of denial decisions and their right to appeal (see Chapter 7 for member appeals information). If you do not submit clinical information, or if the clinical information you submit is not sufficient to support your extension request, we may issue a denial. Tufts Health Public Plans Provider Manual CHAPTER 4D: UTILIZATION REVIEW

101 RECONSIDERATION If we have denied authorization for an inpatient admission, outpatient services, or an elective procedure after an initial determination or a concurrent review determination, you can ask us to reconsider our decision. Reconsideration involves a one-on-one discussion between you and a Tufts Health Public Plans clinical peer reviewer about the details of your patient s case. We will render a reconsideration decision to you within one business day of the request for reconsideration. If we uphold the denial upon reconsideration, your patient may appeal the decision or may designate the provider to appeal on his/her behalf. Reconsideration is not required before your patient can appeal the denial. For more information on member appeals, see Chapter 7. RETROSPECTIVE REVIEW POLICY To assist your ongoing efforts to provide your Tufts Health Public Plans patients with high-quality care and make sure you manage such care appropriately, we reserve the right to retrospectively review all services you provide to your Tufts Health Public Plans patients. We follow the same review process when we need additional clinical information. HOSPITAL ADMISSIONS AND INPATIENT REVIEWS Tufts Health Public Plans evaluates the medical appropriateness of all hospital admissions using nationally recognized InterQual guidelines, along with careful assessment by physician reviewers. In making our decision, we will ask for pertinent clinical information from the treating facility and provider. Our prior authorization process for admissions is as follows: 1. The admitting physician or facility should follow the guidelines in the Notification Requirements section below. 2. The admitting physician or facility should submit the clinical information supporting the medical necessity of the inpatient admission and any elective procedure that is scheduled. 3. After our clinicians review the clinical information from the inpatient facility, we will notify the facility and admitting provider of our final medical determination within one business day of receiving the necessary clinical information. We will send a letter to the facility approving or denying the service within one business day of making our determination. 4. If the inpatient stay extends beyond the initial authorization end date, we need the hospital or attending physician to submit additional clinical information to substantiate the patient s continued stay. We will make a determination within 24 hours of receiving the request. If you do not submit clinical information, or the clinical information you submit is not sufficient to support your extension request, we may issue a denial. 5. In the case of an adverse action/determination (for more information, please see Chapter 7), we will notify the provider rendering the service by telephone within 24 hours and will send written or electronic notification to the patient and the provider to explain our rationale. Tufts Health Public Plans Provider Manual CHAPTER 4D: UTILIZATION REVIEW

102 Notification requirements Elective admissions We must authorize all elective hospital admissions (except for cesarean sections). The admitting facility must obtain prior authorization by submitting a Standardized Prior Authorization Request Form at least five business days before the scheduled admission. Failure to notify us within the required time frame may result in an administrative denial. Observation stays We do not require prior authorization for the first 24 hours of observation, but you will need to get authorization for your Tufts Health Public Plans patient to stay longer than 24 hours. For more information, see our Observation Services Payment Policy. Emergency inpatient hospital admissions Please notify us of all emergency inpatient hospital admissions by the end of the next business day by faxing a Standardized Prior Authorization Request Form to Nonemergency transfers from one facility to another require notification and prior authorization. Please note: We also ask our members to contact their PCP and, if applicable, their behavioral health provider within 48 hours of receiving emergency services to arrange for any necessary follow-up care. Inpatient hospital review process We will conduct an initial review of the clinical information of all Tufts Health Public Plans patients admitted to an inpatient facility, as well as concurrent and discharge reviews. A Tufts Health Public Plans UM physician will review all cases that do not meet the clinical InterQual criteria we use as the basis for our review. We will notify you when a case under clinical review requires additional information and ask that you give us additional relevant clinical documentation to substantiate a continued stay. All concurrent or continued stay reviews require clinical updates from the facility. We will attempt to contact the facility if we do not receive any clinical information. For those cases in which we do not receive clinical information in a timely manner, we may issue an administrative denial. We will discuss alternatives with you and assess your Tufts Health Public Plans patient s continued care, discharge planning, and/or care management needs. We encourage admitting physicians to notify a patient s PCP of any proposed or emergent inpatient admission. We will continue to cover your patient for services until your patient receives notification of the determination, and will not be responsible for the cost of those services if that determination is a denial. When we send you a denial-of-service letter (adverse action or adverse determination) for inpatient services, we will also include a plan-specific member grievances and appeals enclosure. Give the letter and enclosure directly to your patient if they are not discharged so they can decide whether to exercise their right to appeal or file a grievance. For more information on member grievances and appeals, see Chapter 7. OUTPATIENT PROCEDURES Notification requirement We require notification five days prior to the scheduled procedure or service start date. Please fill out the Standardized Prior Authorization Request Form and fax it to We cover surgical day care and/or outpatient surgeries and do not require notification for routine procedures performed by preferred in-network providers at in-network facilities, except for those listed on page 6. Tufts Health Public Plans Provider Manual CHAPTER 4D: UTILIZATION REVIEW

103 Procedures that require prior authorization We must review the following procedures and will authorize the service if we determine it is medically necessary: Abdominoplasty Autologous chondrocyte implant of the knee Blepharoplasty Botox injections Breast procedures (mammoplasty, reconstruction, and enlargement) Chemical peel Cholycystectomy Dermabrasion Earlobe reconstruction Gastroplasty/gastric bypass Hysterectomy Knee arthroscopy, surgical Knee arthroscopy, surgical and osteo Knee arthroscopy, diagnostic Lipectomy (excess fat removal) Other cosmetic procedures Percutaneous vertebroplasty and kyphoplasty Procedures for the treatment of benign prostatic hypertrophy (BHP) Radial keratotomy Rhinoplasty Rhytidectomy (excision of excessive skin and tissue) Salabrasion Sclerotherapy Selective internal radiation therapy Septoplasty Shoulder arthroscopy: diagnostic/therapeutic Shoulder arthroscopy: surgical, surgically assisted Sinusotomy, endoscopic-frontal and maxillary sinus Spinal cord/dorsal column stimulation Spinal procedures, certain elective Subcutaneous injection of filling materials Surgery to correct nearsightedness Tattooing/intradermal introduction of insolvable opaque pigments to correct skin color defect, including micropigmentation Temporomandibular joint (TMJ) disorder treatment Treatment of gynecomastia Upper GI endoscopy: certain elective procedures Varicose vein procedures Tufts Health Public Plans Provider Manual CHAPTER 4D: UTILIZATION REVIEW

104 ANCILLARY AND OTHER SERVICES You must obtain prior authorization for the following services: Certain durable medical equipment (DME) with a combined rental or purchase price greater than $1,000. See our Durable Medical Equipment and Medical Supplies Payment Policy for detailed authorization requirements. Use the Standardized Durable Medical Equipment (DME) and Medical Supplies Prior Authorization Request Form to obtain authorization; the DME vendor will verify the form s information with you. Enteral nutrition formula for Tufts Health Together (MassHealth) patients; please submit the Combined MassHealth MCO Medical Necessity Review Form for Enteral Nutrition Products (Special Formula) with your request for prior authorization Hearing aids that cost more than $500 (Tufts Health Together only) Home health care services if the request is for daily visits or for a duration longer than six months Inpatient rehabilitation and skilled nursing facility (SNF) services Outpatient therapy services (occupational therapy, physical therapy, and speech and language therapy) Pain management services Please refer to our medical benefit summary grids or call us at if you are unsure whether we cover a specific outpatient procedure. Note: All services at an out-of-network or nonpreferred in-network facility require prior authorization and must be initiated by the member s PCP. Prior authorization denial Your Tufts Health Public Plans patient can appeal our decision to deny prior authorization. If your Tufts Health Public Plans patient s health or welfare could potentially be adversely affected, and if your Tufts Health Public Plans patient requests an expedited appeal decision, we will expedite our appeal decision. Your Tufts Health Public Plans patients may also designate you as their authorized representative to exercise these grievance and appeal rights on their behalf. For more information about our grievance and appeals processes, please see Chapter 7. Medical necessity standards We develop our medical necessity guidelines by adhering to standards adopted by national accreditation organizations and gaining input from physicians practicing throughout the state. We regularly update our medical necessity guidelines as new treatments, technologies, and applications are developed and become generally accepted standard medical practice. We use evidence-based standards of care and also consider the individual health care needs of our members when determining medical necessity based on our guidelines. Tufts Health Public Plans medical necessity guidelines are available on Tufts Health Plan's website at tuftshealthplan.com, or contact us at to request a printed copy. Tufts Health Public Plans Provider Manual CHAPTER 4D: UTILIZATION REVIEW

105 Continuity of care Under the conditions below, we will allow members to continue treatment with an out-of-network provider for up to 90 days only if the provider agrees to Tufts Health Public Plans terms related to reimbursement, member co-payments (which cannot be higher than those listed in our medical and behavioral health benefit summary grids), quality, referrals, and additional Tufts Health Public Plans policies and procedures, including the terms and conditions set forth in the Member Handbooks. Tufts Health Public Plans policies on continuity of care are fully compliant with state regulations. EXISTING MEMBERS With prior authorization, an existing Tufts Health Public Plans member may continue to see providers who are no longer in our network (providing they have not been disenrolled for reasons related to quality of care or fraud) when the member: Is pregnant and in her second or third trimester she can continue to see the provider through her first postpartum visit Is terminally ill throughout the illness Is undergoing current or ongoing treatment, such as dialysis, home health, chemotherapy, radiation therapy, or inpatient level of care at a hospital/facility throughout treatment or up to 90 days from date of enrollment, whichever is less Chooses to receive ongoing care from the PCP for up to 31 days NEW MEMBERS A member who is new to Tufts Health Public Plans may continue to see noncontracted providers (with prior authorization) when the member: Is pregnant and in her second or third trimester she can continue to see the provider through her first postpartum visit Is terminally ill throughout the illness Is undergoing current or ongoing treatment, such as dialysis, home health, chemotherapy, radiation therapy, or inpatient level of care at a hospital/facility throughout treatment or up to 90 days from date of enrollment, whichever is less Chooses to receive ongoing care from the PCP for up to 30 days 5343B Tufts Health Public Plans Provider Manual CHAPTER 4D: UTILIZATION REVIEW

106 CHAPTER 5: CLAIMS PROCEDURES We aim to pay you quickly and accurately. Refer to this chapter for information about: Submitting claims Checking claim status Receiving payment reports Requesting claim review Avoiding denials Requesting and applying adjustments Refunding payment or requesting voids Submitting claims You must: Submit a single complete claim for each patient in the Electronic Claim format, with the following exceptions: Submit separate claims for each provider who saw a patient Submit separate claims for each site where a patient received services Submit all claims within 90 days of the date of service Please submit complete and accurate claims. Missing or invalid data may cause a delay of payment or denial or return of your claim. You should always: Check patient eligibility on the date of service. Please see Chapter 2 for details on the ways to verify eligibility, and remember to keep proof of eligibility for your records. File initial claims electronically. You can check the status of electronic claims online on the business day following submission. Submit claims to Tufts Health Public Plans for services we cover. DO NOT send claims to the Health Connector, MassHealth, or other state agencies for your Tufts Health Public Plans patients. Prior to submission, make sure claims: Meet all prior authorization requirements and include the authorization number, if applicable Include both your National Provider Identifier (NPI) and tax ID numbers. Per the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements, all claims must contain your NPI number for us to pay you. Are on a Centers for Medicare & Medicaid Services (CMS) CMS-1500 (professional) or CMS-1450 (facility) claim form for paper claims submissions; for procedures performed in a hospital, submit separate claims for hospital services and a provider s professional service charge Tufts Health Public Plans Provider Manual CHAPTER 5: CLAIMS PROCEDURES

107 METHODS FOR CLAIM SUBMISSION Electronic claims Submit claims electronically to save time and money. We offer your practice five ways to submit electronic claims: Tufts Health Provider Connect access Tufts Health Provider Connect, our self-service tool, to submit individual CMS-1500 and CMS-1450 claims electronically. Through Tufts Health Provider Connect, you can also check claims status, view claims details, and much more. For more details, please see Chapter 8. Direct electronic data interchange (EDI) submission this method is ideal if you submit a large volume of claims to us. You can submit electronic claims files through secure file transfers, as well as through virtual private network (VPN) transmission. Direct claims submission is free and offers you customized reporting and increased control over testing and processing. For more information, please us at EDI_Operations@tufts-health.com or call us at x54042 and ask to speak with an EDI specialist. New England Healthcare Exchange Network (NEHEN) NEHEN is a consortium of regional payers and providers that offers a secure and innovative e-commerce solution for claims submission and other health care transactions. Visit NEHEN for information on how to join, or call them at NEHENNet the NEHEN consortium collaborated on a single website called NEHENNet, which allows smaller practices and providers with less IT support to manage the most popular and essential transactions for a fixed monthly fee. Visit NEHENNet for more information, send an to ask for an invitation to a weekly webinar, or call NEHENNet at Clearinghouse submission we accept professional and institutional EDI claims via the MD On-Line clearinghouses. Make sure you update the clearinghouse with the Tufts Health Plan s payer ID number: MD On-Line for questions about setup and connectivity, please visit MD On-Line, call , or read about the special offer for Tufts Health Public Plans providers. Other clearinghouses for questions about setup and connectivity to another clearinghouse, or how to appropriately configure your clearinghouse s software, please us at EDI_Operations@tufts-health.com, or call us at x54042 and ask to speak with an EDI specialist. To get started or ask questions about submitting electronic claims, us at EDI_Operations@tufts-health.com, or call us at x54042 and ask to speak with an EDI specialist. For quality assurance purposes, you must complete our testing procedures. Your provider relations representative will help coordinate the testing and implementation process with our EDI team. To submit claims electronically, include your: NPI number if you need your NPI number, please call us at Tax ID number Payment address For more details about our electronic capabilities, please see information about Tufts Health Provider Connect in Chapter 8. Please note: When submitting any claim that requires an attachment, such as an invoice or other documentation (e.g., for coordination of benefit claims), you must submit by paper. Tufts Health Public Plans Provider Manual CHAPTER 5: CLAIMS PROCEDURES

108 Paper claims While there are many benefits to filing electronically, sometimes you must submit paper claims (e.g., claims that require attachments). You can expect to see claims you submit by paper on your Explanation of Payment (EOP) Report within 30 days. Submit all initial paper claims to: Tufts Health Plan P.O. Box 8115 Park Ridge, IL Mail all claim corrections, timely filing override requests, and electronically denied claims corrections to: Tufts Health Plan Attn: Provider Services P.O. Box 9194 Watertown, MA TYPES OF CLAIM SUBMISSION Professional services claims You must file all claims for professional services, including laboratory services performed by an independent laboratory, on the CMS-1500 Claim Form. If you file electronically, use the 837 Professional HIPAA transaction file. Include all required data on your claims forms so we do not have to delay payment or deny or return a claim. Through Tufts Health Provider Connect, you can look up procedure and diagnosis codes. Follow these instructions to complete each claim: Get an NPI number before submitting a claim if you are a nonancillary provider. Validate all procedure and diagnosis codes submitted for the date of service and bill to the fourth- and fifth-digit specification when appropriate. Bill all procedure codes with a modifier when applicable. Submit all anesthesia claims with the total number of anesthesia minutes of face-to-face attendance time for all services and bill with the appropriate anesthesia code; do not submit surgery procedure codes for anesthesia services. Give us medical records to review for payment accuracy upon request. Tufts Health Public Plans Provider Manual CHAPTER 5: CLAIMS PROCEDURES

109 Required fields for submitting professional claims CMS-1500 (paper) Block # Required or Not Required 1 N 1a* R 2** R 3 R 4** R 5** R 6 R 7** R 8 R 9 R 9a R 9b N 9c R 9d R 10a-c R 11 N 11a N 11b R 11c R 11d R 12 R 13 R 14 R 15 N 16 N 17 R 17a R CMS-1500 (paper) Block # Required or Not Required 18 N 19 N 20 N 21 R 22 R 23 R 24a R 24b R 24c R 24d R 24e R 24f R 24g R 24h R 24i N 24j R 24k N 25 R 26 N 27 R 28 R 29 R 30 R 31 R 32 R 33 R * In Block 1a, enter the member s unique Tufts Health Public Plans identification number, which begins with N. For information on required fields for electronic filing, use the code lookup feature in Tufts Health Provider Connect or call us at Tufts Health Public Plans Provider Manual CHAPTER 5: CLAIMS PROCEDURES

110 Hospital and facility claims File all hospital and facility claims, including laboratory services, using the CMS-1450 Claim Form. If you file electronically, use the 837 Institutional HIPAA file. For procedures performed in a hospital, bill the provider s professional service charges separately on a form. You can look up procedure and diagnosis codes through Tufts Health Provider Connect. Follow these instructions to complete each hospital and facility claim accurately: Validate all procedure and diagnosis codes submitted for the date of service and bill to the fourth- and fifth-digit specification when appropriate. Include the prior authorization number on all inpatient submissions. Submit the attending physician s name and Massachusetts license number on the claim form. Give us medical records to review upon request, for payment accuracy. Required fields for submitting hospital and facility claims CMS-1450 (paper) Block # Required or Not Required 1 R 2 R 3a R 3b R 4 R 5 R 6 R 7 R 8a R 8b N 9a R 9b N 9c N 9d N 9e N 10 R 11 R 12 R 13 R 14 R 15 R 16 R 17 R 18 R 19 R CMS-1450 (paper) Block # Required or Not Required 20 R 21 R 22 R 23 R 24 R 25 R 26 R 27 R 28 R 29 R 30 R 31 R 32 R 33 R 34 R 35 R 36 R 37 N 38 N 39 R 40 R 41 R 42 R 43 R 44 R Tufts Health Public Plans Provider Manual CHAPTER 5: CLAIMS PROCEDURES

111 CMS-1450 (paper) Block # Required or Not Required 45 R 46 R 47 R 48 R 49 N 50 R 51 R 52 R 53 R 54 R 55 N 56 R 57 N 58 R 59 R 60* R 61 N 62 N 63 R 64 N 65 R 66 N 67 R CMS-1450 (paper) Block # Required or Not Required 68 R 69 R 70 R 71 R 72 R 73 N 74 R 74a N 74b N 74c N 74d N 74e N 75 N 76 R 77 R 78 N 79 N 80 R 81a R 81b R 81c R 81d R * In Block 60, enter the member s unique Tufts Health Public Plans identification number, which begins with N. For information on required fields for electronic filing, use the code lookup feature on Tufts Health Provider Connect or call us at CODING HIPAA transactions and codes We are fully compliant with federal government regulations regarding the privacy of protected health information as outlined in HIPAA. We keep any protected health information sent to us strictly confidential and securely store this information once it is on our premises. For more information, you can read about HIPAA and how we protect the privacy of your Tufts Health Public Plans patients protected health information. Diagnosis coding We will accept diagnosis codes published in the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) with a date of service through September 30, All claims with a date of service on October 1, 2015, and later will only be processed in the ICD-10 format. The October 1, 2015, transition date to ICD-10 complies with federal mandates. Tufts Health Public Plans Provider Manual CHAPTER 5: CLAIMS PROCEDURES

112 Bill all ICD-9 codes to the fourth- and fifth-digit specification when appropriate. You can look up procedure and diagnosis codes through Tufts Health Provider Connect. Federal and state legislation imposes stringent penalties for failing to keep confidential certain highly sensitive information, such as substance abuse treatment and AIDS-related information. These laws, however, are not intended to prevent providers from accurately and appropriately submitting claims to health plans. Submit all diagnosis codes for sensitive diagnoses on the claim form accurately. Procedure coding We use the Healthcare Common Procedure Coding System (HCPCS) to identify services you provide to your Tufts Health Public Plans patients. HCPCS codes include current procedural terminology (CPT) codes, as well as codes CMS develops. Due to HIPAA requirements, we do not accept any nonstandard codes. We accept standard HCPCS Level I and Level II codes. Submit modifiers with procedure codes when appropriate (see our payment policies for more information on using modifiers). We may request operative or clinical notes for all unlisted procedures and for specific codes or code combinations. Please use unlisted procedure codes only when no other code exists for the services provided. BILLING Third-party liability Third-party liability (TPL) describes a situation in which your Tufts Health Public Plans patients have additional coverage that pays for their care. According to federal and state regulations, you must bill all available carriers before any managed care organization covering a MassHealth or Health Connector member will reimburse you. In cases where a member has another commercial plan available, after you receive claim processing notification from the primary payer, bill us as the secondary insurer. We are the payer of last resort. When filing a claim for a member with third-party resources: Attach documentation to the CMS-1500 or CMS-1450 form showing claims processing results from the primary payer. Attach a copy of the TPL carrier s EOP, denial notice, and benefits-exhausted statement to include both personal injury protection (PIP) and MedPay (auto insurance covering medical and funeral expenses resulting from an accident for the policyholder and any passengers riding with the policyholder) for claim payment. The primary insurance carrier s EOP must contain the date the claim was processed or the check date. Also, you need to submit a description of any remark codes indicated on the EOP. We will not pay a claim if the reason for a TPL carrier s denial is a claim preparation error or because sufficient information to process the claim was not received. Include a copy of the primary carrier s EOP and check when: Reimbursing us by check, or Submitting a claim retraction request due to payment by a motor vehicle, workers compensation, health, or other third-party insurer. If we receive your claim more than 60 calendar days after the date of denial or processing date from the third-party carrier, we will deny it. Tufts Health Public Plans Provider Manual CHAPTER 5: CLAIMS PROCEDURES

113 Notify our TPL recoveries team when attorneys or insurance companies request copies of a member s medical records or bills. Fax a copy of the letter to the TPL recoveries team at Balance billing As part of our contracting guidelines, Tufts Health Public Plans in-network providers must accept as payment in full monies paid in accordance with applicable fees, rates, and amounts established under your provider agreement and applicable reimbursement regulations. Therefore, providers are prohibited from balance billing members. You should only bill members for services not covered by Tufts Health Public Plans. If you are going to provide a service not covered by one of our plans, please inform your patients before the procedure, and let them know you will directly bill them and what you will charge for that particular service. Failure to explain to patients in advance that the service will cost them money may result in not getting paid. You also may not bill Tufts Health Public Plans patients for missed appointments. TIMELY FILING We deny claims we do not receive within 90 days of the date of service. Acceptable forms of proof of timely filing for proof of eligibility include an Eligibility Verification System (EVS) printout or screenshot. The acceptable formats for filing proof of electronic submissions are either a rich text format (RTF) document or a 277 transaction report to the direct submitter or clearinghouse that indicates the claim was submitted and accepted by Tufts Health Public Plans within timely filing limits. For more information, see our Timely Filing of Claim Submissions and Adjustment Requests Payment Policy. Checking claim status To check the status of a claim 24 hours a day, seven days a week, use Tufts Health Provider Connect. You can review the status of an electronic claim the business day following submission. Please have the following information available to expedite checking a claim s status: The patient s name The patient s Tufts Health Public Plans member ID number The claim number, if applicable The date of service The amount billed The authorization number, if applicable Your patient account number Your NPI number and your tax ID number You can also check the status of submitted claims through NEHEN within one business day, if your organization is a member. Tufts Health Public Plans Provider Manual CHAPTER 5: CLAIMS PROCEDURES

114 Alternatively, you can also call us at , Monday through Friday, from 8 a.m. to 5 p.m., to check claims status. We will only check claim status for up to five members per call. For first-time claim submissions, please allow 30 days for processing. Receiving payment reports We send two types of reports related to claims payment, depending on your method of claim submission. EOP REPORT If you submit paper claims, you will receive an EOP Report with checks for payment and claim denials. This report reflects claims submitted on paper that we paid or denied during the previous period. All denied claims will have denial codes and our reasons for denying the claim. If the explanation is unclear, please contact us at ELECTRONIC DATA INTERCHANGE (EDI) REJECT REPORT If you submit claims via direct EDI submission, we will send you an EDI Reject Report electronically if we do not accept your claim. Claims that appear on our EDI Reject Report will not appear on your EOP Report and are not active for processing in our claims system. You must correct and resubmit these claims on paper for processing within the timely filing limits, or within 60 days from the date of the EDI Reject Report. If you resubmit a claim within 60 days from the date of the EDI Reject Report, but 90 days or more past the date of service, please resubmit on paper with a copy of the Tufts Health Public Plans EDI Reject Report. We may deny your claim if you do not follow timely filing limits and these instructions. Requesting claim review We offer our providers the opportunity to submit a request for claim review, including corrected claim submissions. As indicated on the Request for Claim Review Form, you can resubmit a claim for review for reasons such as: Coordination of benefits we denied your claim because we needed information from another insurer before processing and you believe the denial is inappropriate. Corrected claim you are submitting a corrected claim because the original claim had missing, inaccurate, or invalid data. Please complete the Request for Claim Review Form and attach the paper corrected claim. Indicate corrected claim at the top of the paper corrected claim. To submit a paper corrected claim: Print out or hand-write a new claim with corrected information. Write Corrected Claim and the original claim number at the top of the claim. Circle all corrected claim information. Attach the Explanation of Payer (EOP)/remit advice from the original claim. Indicate the item(s) needing correction. Tufts Health Public Plans Provider Manual CHAPTER 5: CLAIMS PROCEDURES

115 Highlight new or updated data elements on the claim. Submit the claim in the time frame specified by the terms of your contract to: Tufts Health Plan Attn: Provider Services P.O. Box 9194 Watertown, MA Duplicate claim we denied your claim as a duplicate claim submission and you believe the denial is inappropriate. Filing limit we denied your claim due to untimely filing. For more information, see our Timely Filing of Claim Submissions and Adjustment Requests Payment Policy. Prior authorization we denied your claim due to failure to obtain prior authorization or referral, or for including services that were different from what we authorized. Reduced payment or retraction of payment we underpaid your claim and you would like to request additional payment, or we overpaid your claim and you would like to report the overpayment to us. You believe the underpayment or overpayment may be the result of a Tufts Health Public Plans error or other billing error. Request for additional information we denied your claim due to lack of supporting documentation and you would like to submit the required documentation. For more detail, please see the Review Type section of the Request for Claim Review Form. You can submit a request for claim review in writing. We must receive your request for claim review within 60 days of the EOP Report date. If you believe we incorrectly denied a claim or would like a claim review for any reason, please submit a completed Request for Claim Review Form along with your claim and supporting documentation. Send this request to: Tufts Health Plan Attn: Provider Services P.O. Box 9194 Watertown, MA Your request for claim review must include the following information: Date of service Reason for request Claim number Clinical information (if applicable) Contact name and address for the request for communication purposes A claim you submit for correction must be a complete claim, including all other encounter data for that date of service. Tufts Health Public Plans Provider Manual CHAPTER 5: CLAIMS PROCEDURES

116 The corrected claim must also include: Clear identification of corrected and/or added information The words corrected claim on the claim You can use the Request for Claim Review Form to ensure we have all the information necessary to begin reviewing your request. Submit a request for claim review, including corrected claim submissions, by mail to the same address: Tufts Health Plan Attn: Provider Services P.O. Box 9194 Watertown, MA You can also submit an initial request for claim review by calling us at Please refer to Chapter 7 for information on member appeals. Avoiding denials To avoid claim denials, make sure to follow all claim procedures described in this chapter. We may deny payment of a claim if you: Do not include your NPI and tax ID number Request payment for a service that is not a covered benefit Did not get prior authorization (for services requiring one) Do not provide enough clinical information to support the requested service Submit an incomplete claim form Submit the claim more than 90 days after the date of service Always be sure to verify your Tufts Health Public Plans patient s eligibility on the date of service. We will deny a claim if the member was not eligible on the date of service. As a reminder: we do not determine eligibility. If we deny your claim, you can request a claim review by following the process outlined in the section on requesting a claim review above. Tufts Health Public Plans Provider Manual CHAPTER 5: CLAIMS PROCEDURES

117 Requesting and applying adjustments We will review requests made within the appropriate time frames to adjust any overpaid or underpaid claims. We evaluate overpayments and underpayments on a case-by-case basis to determine appropriate action. We will either apply adjustments to future paid claims or request a refund check from you in the case of overpayment. We may initiate adjustment for up to 24 months after the original Tufts Health Public Plans EOP date. If we apply adjustments to future payments, the EOP Report will identify the adjustment, member name, member ID number, claim number, provider name, and correct payment amount. If an overpayment causes the adjustment and the retraction results in a negative balance, we will not send additional payment until we receive additional claims to offset the negative balance. For more information, please see our Payment Adjustments Payment Policy. If you have any questions regarding the receipt of an overpayment or underpayment, please call us at Refunding payment or requesting voids If you receive a payment you feel is inappropriate, please call us at before sending a refund check. Direct all provider refund checks or issues about Tufts Health Public Plans checks, including requests for stop payments or voids, to: Tufts Health Plan Attn: Provider Services P.O. Box 9194 Watertown, MA B Tufts Health Public Plans Provider Manual CHAPTER 5: CLAIMS PROCEDURES

118 CHAPTER 6: CREDENTIALING PROCEDURES We want to help you become or continue as a participating in-network provider for our members. Please refer to this chapter for information about: Provider credentialing Provider recredentialing Provider suspension, termination, or sanction Provider credentialing rights (non-facility) Facility credentialing Laboratory credentialing Behavioral health (BH) facility credentialing Provider credentialing Tufts Health Public Plans providers must meet our contracting and credentialing requirements. Only providers who have completed the contracting and credentialing process may render services to our members. Tufts Health Public Plans works with the Council for Affordable Quality Healthcare (CAQH) to obtain provider credentialing information through a central data repository called the universal provider database. All providers must enter their credentialing information through that database. We require the following to credential providers: 1. A completed profile through CAQH, including: License number Drug Enforcement Administration (DEA) certificate, if applicable Five-year work history in a month/day/year format Malpractice liability face sheet information, including name of carrier, dates of coverage, and amount of coverage 2. An HCAS Provider Enrollment Form 3. A signed contract Tufts Health Public Plans Provider Manual CHAPTER 6: CREDENTIALING PROCEDURES

119 We credential the following types of licensed providers: Physicians, including but not limited to medical doctors, doctors of osteopathy, and podiatrists Dentists (for medical purposes) Other allied health professionals, including but not limited to: registered nurses, nurse practitioners, physician assistants, certified nurse midwives, chiropractors, optometrists, physical therapists, speech therapists, occupational therapists, registered dieticians, nutritionists, audiologists, acupuncturists, and others We credential the following behavior health (BH) providers: Psychiatrists and other physicians Addiction medicine specialists Doctoral or master s-level psychologists Master s-level clinical social workers Master s-level clinical nurse specialists or psychiatric nurse practitioners Other BH care specialists Once you complete a CAQH credentialing profile and submit a signed contract and HCAS Provider Enrollment Form, we begin the credentialing process. Please see provider credentialing rights for additional information about provider rights. There is no right of appeal for initial applications. We will notify you once our credentialing committee makes a decision on your application. Providers become effective with Tufts Health Public Plans on the date the credentialing committee approves their application. Throughout the credentialing process, CAQH, Aperture (our credentialing vendor), and Tufts Health Public Plans will make reasonable attempts to collect all required information. If we do not receive the requested information after multiple attempts, Tufts Health Public Plans will deem the application incomplete and will discontinue your credentialing application. If you do not provide the information within 30 calendar days of our final request, we will consider your credentialing application withdrawn and will notify you of this decision. BOARD-CERTIFICATION POLICY Physicians seeking credentialing must be board-certified or in the process of receiving certification after completing requisite board education and training within a time frame set by the applicable specialty. Board-certified physicians must maintain certification in accordance with their applicable specialty board guidelines. If physicians do not maintain board certification in at least one clinical specialty, we may terminate their network participation. New physicians who are eligible but not yet certified, such as physicians who have finished the applicable training and education but have not yet obtained board certification, are exempt from the board-certification requirement. We will only excuse the board certification requirement provided that no more than six years or two exam cycles, whichever is greatest, have elapsed since the physician completed residency in the applicable medical specialty. Tufts Health Public Plans Provider Manual CHAPTER 6: CREDENTIALING PROCEDURES

120 Additionally, we may contract with physicians who have training consistent with board eligibility but who are not board-certified. In such circumstances, on a case-by-case basis, Tufts Health Public Plans will submit documentation describing the business need that we are trying to address by adding a non-board-certified physician to our network for review and approval by the Executive Office of Health and Human Services. We may consider credentialing physicians who demonstrate in their initial Tufts Health Public Plans application that they have been in practice for 10 or more consecutive years and did not meet the criteria necessary to take the applicable certification examination. From these physicians we require three letters of reference as well as documentation of continuing medical education. Provider recredentialing To meet regulatory and accreditation guidelines, we recredential all of our providers at least every three years (or more frequently as required by state, federal, or accrediting agencies). CAQH will notify you and send you instructions when it is time to update your profile. Your updated information will be processed, and in the event of any concern, you will be promptly notified. Throughout the recredentialing process, CAQH, Aperture, and Tufts Health Public Plans will make reasonable attempts to collect all required information. If we do not receive the requested information after multiple attempts, Tufts Health Plan will deem the application incomplete and will not move forward with your recredentialing application. If you do not provide the information within 30 calendar days of our third request, we will consider your recredentialing application withdrawn and participation terminated, and we will notify you of this decision. Please make sure to keep your contact information updated with us so we can more easily stay in touch with you during the recredentialing process. Update your information with us via the Medical or Behavioral Health Provider Information Form, or by calling your provider relations representative at Provider suspension, termination, or sanction If MassHealth, the Health Connector, and/or another state s Medicaid program or other agency suspends, terminates, or sanctions you, your Tufts Health Public Plans provider status will be updated to reflect the same status. When you resolve any outstanding issues to the satisfaction of the agency and they have changed your status, Tufts Health Public Plans will update your status accordingly. You must notify us immediately of any disciplinary actions a governmental agency or licensing board takes against you or if you know of any such confirmed or pending disciplinary actions. We monitor the Board of Registration in Medicine (BORIM), Office of Inspector General (OIG) List of Excluded Individuals/Entities (LEIE), the Medicare Exclusion Database, and the Service Agreement Management System. Tufts Health Public Plans Provider Manual CHAPTER 6: CREDENTIALING PROCEDURES

121 In the event there is a disciplinary action or evidence of serious quality issues, our credentialing committee will determine if there will be a change to your credentialing status, or suspend or terminate your contract. Quality issues that could cause us to suspend or terminate you may include: Refusing to comply with any of our provider contract provisions Failing to comply with federal, state, or local clinical or administrative practice requirements or regulations Failing to maintain full and unrestricted licensure Failing to obtain or maintain board-certified status (if you have a board certification, you must maintain that status) Failing to maintain active hospital privileges Failing to comply with acceptable ethical and professional standards of behavior You must notify us immediately if another health plan or other institution terminates you for: Refusing to comply with any contract element that also appears in our provider contract with you Failing to comply with federal, state, or local clinical or administrative practice requirements or regulations Failing to maintain full and unrestricted licensure Failing to obtain or maintain board-certified status (if you have a board certification, you must maintain that status) Failing to maintain active hospital privileges, as applicable Failing to comply with acceptable ethical and professional standards of behavior You must also notify us immediately about: Suspension, termination, or sanctions from MassHealth, the Health Connector, or another state s Medicaid program Suspension from the Massachusetts BORIM or other applicable board If our credentialing committee decides to terminate or suspend you, we will notify you of the decision within three business days. Tufts Health Public Plans Provider Manual CHAPTER 6: CREDENTIALING PROCEDURES

122 Provider credentialing rights (non-facility) An overview of the rights of our providers follows. All provider credentialing is completed by the Tufts Health Public Plans credentialing department. Providers have the right, upon written request, to review Tufts Health Public Plans credentialing policies and procedures. Providers have the right, upon request, to be informed of the status of their credentialing or recredentialing application. Upon request, the credentialing department may notify the provider of the receipt date, the date the application is considered complete and ready for verification (e.g., elements including license, DEA, malpractice insurance information), and the final committee review date. Providers have the right to review information submitted to Tufts Health Public Plans for purposes of credentialing or recredentialing the provider, including information obtained by Tufts Health Public Plans from any outside primary source, such as a malpractice carrier, state license board, or the National Practitioner Data Bank (NPDB). Tufts Health Public Plans shall notify providers of this right to review. Notwithstanding the foregoing, Tufts Health Public Plans is not required to reveal the source of information if the information was not obtained for the purpose of meeting Tufts Health Public Plans credentialing requirements. Providers are not entitled to review references, recommendations, information that is peer-review privileged, or information that by law Tufts Health Public Plans is prohibited from disclosing. Tufts Health Public Plans shall notify providers in the event that credentialing information that it has obtained from sources other than the provider varies substantially from credentialing information provided to Tufts Health Public Plans by the provider. Tufts Health Public Plans is not required to reveal the source or contents of the information if the information is not obtained for the purpose of meeting Tufts Health Public Plans credentialing requirements. Providers have the right to correct erroneous information submitted by another party, and Tufts Health Public Plans shall notify providers of their right to correct erroneous information. In the event the Quality of Care Committee (QOCC) votes to take disciplinary action, the provider is entitled to notice consisting of a written statement of the reasons for the action and, if applicable, has the right to appeal such action by filing a written appeal within thirty (30) days of receipt of the statement of reasons. For providers practicing in Rhode Island, if a credentialing decision is made to deny credentials to a provider, the QOCC sends the provider written notification of all reasons for the denial within sixty (60) days of receipt of the completed and verified application. A disciplinary action notice will include a summary description of the appeals process. If the provider exercises his or her appeal right, QI Program Director/Chair of QOCC will arrange for a hearing before an Appeals Committee that will review the decision of the QOCC and issue a decision prior to implementation of the disciplinary action against the provider. The provider is entitled to be represented by an attorney or other representative of the provider s choice. In the event that new information becomes available, the provider may submit new information up until the Appeals Committee meeting. Each committee member must engage in a fair and impartial review of the provider s appeal. No committee member may be an economic or geographic competitor of the reviewing provider. The committee member should not be employed by or act in the capacity of a Tufts Health Public Plans Board member or otherwise be a representative of Tufts Health Public Plans. The decision of the Appeals Committee is final. The provider will be given written notification of the appeal decision that contains the specific reasons for the decision. Tufts Health Public Plans Provider Manual CHAPTER 6: CREDENTIALING PROCEDURES

123 Facility credentialing At the time of contracting with us, we ask facilities to complete and return the contracting package to us. Our credentialing team will review the documentation for completeness and current, valid licensure and then submit the package to the credentialing committee for review. We credential the following types of facilities: Acute-care and rehabilitation hospitals Ambulatory care centers Skilled nursing facilities Home care agencies Hospice agencies Free-standing imaging centers Facilities the Department of Mental Health licenses as mental health or substance-use clinics We require the following from facilities before we begin the credentialing process: A current and valid license Current and valid accreditation, as applicable A Tufts Health Public Plans Medical or Behavioral Health Provider Information Form (PIF) Form W-9 Completed Federally Required Disclosures Form Complete copy of the most recent site visit, if not accredited; if there is no recent site visit, Tufts Health Public Plans may perform one After the credentialing committee reviews the credentialing application, we contact facilities to inform them whether or not we have approved their credentials. There is no right of appeal for facilities. Facilities will be recredentialed at least every three years or more frequently as required by state, federal, or accrediting agency requirements. Tufts Health Public Plans Provider Manual CHAPTER 6: CREDENTIALING PROCEDURES

124 LABORATORY CREDENTIALING We credential clinical laboratories in accordance with the federal Clinical Laboratory Improvement Amendments (CLIA). We require credentialed laboratories to: Have a current, unrevoked, or unsuspended certificate of waiver, registration certificate, certificate of compliance, certificate for provider-performed microscopy (PPM) procedures, or certificate of accreditation issued by the U.S. Department of Health and Human Services applicable to the category of examinations or procedures performed by the laboratory, or Be CLIA-exempt, as defined in 42 CFR 493.2, or satisfy an exception set forth in 42 CFR 493.3(b) There is no right of appeal for laboratories. Laboratories will be recredentialed at least every three years or more frequently as required by state, federal, or accrediting agency requirements. Behavioral health (BH) facility credentialing In addition to the requirements outlined in this chapter, BH providers must meet state and federal regulatory requirements, including but not limited to the Department of Mental Health (DMH) regulations for licensing of mental health facilities, as described in 104 CMR 27, for network inclusion. For more information about our BH program, see Chapter 4B. We use the following criteria to credential any BH facility or clinic provider: The provider must be licensed by the Commonwealth of Massachusetts. The facility may be accredited by the Joint Commission (formerly the Joint Commission on the Accreditation of Healthcare Organizations) or another Tufts Health Public Plans-recognized accreditation organization. If not accredited, other requirements apply (e.g., a recent site visit by DPH or Tufts Health Public Plans). The provider must meet our site review requirements, including but not limited to demonstrating age- and population-appropriate services, assessments, and restrictions for all defined specialty populations. The provider must have an organized and fully implemented quality management plan. The provider must not discriminate or restrict access on the basis of sex, race, creed, physical disability, national origin, sexual orientation, or ability to pay, and must make services available to any person in the commonwealth. The provider should work with one of our contracted Emergency Services Program (ESP) providers to ensure Tufts Health Public Plans patients can access more intensive levels of psychiatric intervention when a condition warrants additional emergent psychiatric intervention. Programs must also maintain procedures to ensure emergent medical care access for all Tufts Health Public Plans patients. Tufts Health Public Plans Provider Manual CHAPTER 6: CREDENTIALING PROCEDURES

125 Additionally, hospitals that provide BH inpatient services must: Follow a human rights protocol that is consistent with DMH requirements and includes training of staff and education of patients regarding human rights Have a human rights officer, overseen by a human rights committee, and provide written materials to patients regarding their human rights, in accordance with DMH requirements There is no right of appeal for BH facilities. BH facilities will be recredentialed at least every three years or more frequently as required by state, federal, or accrediting agency requirements. 5343B Tufts Health Public Plans Provider Manual CHAPTER 6: CREDENTIALING PROCEDURES

126 CHAPTER 7: RIGHTS AND RESPONSIBILITIES We want to make sure you are aware of your rights and responsibilities, as well as those of your Tufts Health Together (MassHealth) and Tufts Health Direct (Qualified Health Plan) patients as they relate to filing grievances and appeals and conducting permissible marketing activities. You should also be aware of our policies regarding provider termination. Refer to this chapter for information about: Provider requests for claim review Provider termination Provider grievances Member grievances, appeals, rights, and responsibilities Definition of terms Member grievances Member appeals Member rights and responsibilities Permissible marketing activities Please see Chapter 9 for specific rights and responsibilities information regarding Tufts Health Unify. Provider requests for claim review If you have already provided services to your Tufts Health Public Plans patient and you disagree with a claim denial or you need to provide additional or corrected information, you may submit a request for claim review. Please see Chapter 5 for more information about our claims procedures, including submitting requests for claim review. Provider termination We value your participation in our network and strive for long-term partnerships with you, but we recognize you may decide not to renew a contract with us. In accordance with the agreement you sign when you join our network, you must give us 90 days advance notice in writing of your intent not to renew your contract. After you tell us, we will notify your Tufts Health Public Plans patients that you will no longer be affiliated with our network. To facilitate continuity of care, whenever possible, we permit members to continue ongoing courses of treatment with their current provider during a transitional period from the time we notify the member about the provider s termination. You must make available, pursuant to your provider contract, a transitional period when a member asks for one. When appropriate, we will work with you to reassign your Tufts Health Public Plans patients to an in-network provider. For information about patient continuity of care, please see Chapter 4D. For information about involuntary provider suspension or termination, which we address through credentialing, please see Chapter 6. Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

127 Provider grievances As a provider, you may file a grievance if you are dissatisfied with any interaction in the process of doing business with us. You may file a grievance by: send us an to AppealandGrievanceTeam@tufts-health.com Telephone call us at , Monday through Friday, from 8 a.m. to 5 p.m., excluding holidays Mail mail a letter explaining the grievance and including all relevant documentation to us at: Tufts Health Plan Attn: Appeal and Grievance Team P.O. Box 9194 Watertown, MA Fax fax a letter explaining the grievance to us at Member grievances, appeals, rights, and responsibilities We understand that you strive to provide quality care to all of your patients, and we appreciate your partnership with us. Because members may designate you to exercise rights on their behalf as an authorized representative, you should know our grievance processes and the rights members have. For inpatient grievances and appeals, you do not need to be designated as an authorized representative for the appeal process to proceed. However, we do require that Tufts Health Together members complete an Authorized Representative Form as documentation that the member did in fact authorize you to file the expedited appeal or grievance on their behalf. We do not retaliate or take any punitive action against a provider who requests an expedited resolution or supports an enrollee s appeal or grievance. DEFINITION OF TERMS For all Tufts Health Public Plans members An authorized representative is a person authorized in writing or allowed by law to act on a member s behalf regarding a specific grievance, grievance decision review, internal appeal, or external review. If a Tufts Health Public Plans member is not able to pick an authorized representative, in a case where one is needed, a guardian, conservator, holder of a power of attorney, or family member, in that order of priority, may be named the member s authorized representative or may pick another person to be the member s authorized representative. If the member is a minor and is able by law to consent to a medical procedure, they can also pick an authorized representative without the consent of a parent or guardian. A grievance is when a Tufts Health Public Plans member or a member s authorized representative tells us they are dissatisfied with any action or inaction other than an adverse action (for Tufts Health Together members) or adverse determination (for Tufts Health Direct members). Grievances may relate to quality of care or services provided; aspects of interpersonal Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

128 communication, such as a provider or Tufts Health Public Plans employee s unprofessional behavior; failure to respect a member s rights; a disagreement a member may have with our decision not to approve a request that an internal appeal be expedited; or a disagreement with our request(s) to extend the time frames for resolving an authorization decision or an internal appeal. An internal appeal is an oral or written request for Tufts Health Public Plans to review any adverse action/determination. An external review is a request for an external review agency to review Tufts Health Public Plans final internal appeal decision. An expedited appeal is an oral or written request for an expedited review of an adverse action/determination when a member s life, health, or ability to attain, maintain, or regain maximum function will be at risk if we follow our standard time frames when reviewing the member s request. For Tufts Health Direct members An adverse determination is a decision, based upon a review of information the member or the member s authorized representative provides to us or our designated utilization review organization to deny, reduce, modify, or end an admission, continued inpatient stay, or the receipt of any other services for failing to meet the requirements for coverage based on medical necessity, appropriateness of health care setting, and level of care or effectiveness. For Tufts Health Together members Adverse actions (whether actions or inactions) are when: We deny payments for all or part of a requested service A provider fails to provide covered services within the time frames we describe in the Tufts Health Together Member Handbook We deny or limit authorization for a requested service We reduce, suspend, or end a service we previously authorized We do not act on a prior authorization request within the time frames we describe in the Tufts Health Together Member Handbook We do not follow the internal appeal time frames we describe in the Tufts Health Together Member Handbook An external review (fair hearing) is a written request to the Executive Office of Health and Human Services (EOHHS), Office of Medicaid s Board of Hearings (BOH) to review Tufts Health Public Plans decisions on first-level, second-level, or expedited appeals. EOHHS refers to an external review as a fair hearing. First-level internal appeals are oral or written requests for Tufts Health Public Plans to review an adverse action. A grievance decision review is our process for reviewing one of our grievance decisions at your request as a Tufts Health Public Plans member s authorized representative. Second-level internal appeals are oral or written requests for Tufts Health Public Plans to review a first-level internal appeal denial. Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

129 MEMBER GRIEVANCES As a member s authorized representative, you may file a grievance up to 180 calendar days after the action or inaction for a Tufts Health Together member, in the following ways: Telephone call us at , Monday through Friday, from 8 a.m. to 5 p.m., excluding holidays TTY/TTD people with hearing loss can call our TTY line at , Monday through Friday, from 8 a.m. to 5 p.m., excluding holidays Mail mail a grievance to us at: Tufts Health Plan Attn: Appeal and Grievance Team P.O. Box 9194 Watertown, MA a grievance via the Contact us section of our website Fax fax a grievance to us at In person visit our office at 705 Mount Auburn Street, Watertown, MA 02472, Monday through Friday, from 8 a.m. to 5 p.m., excluding holidays We will not take action on a member s grievance from someone other than the member unless the member signs an Authorized Representative Form designating an authorized representative. You or a member can get the form by calling member services or our appeal and grievance team at , Monday through Friday, from 8 a.m. to 5 p.m. If we do not get the signed Authorized Representative Form within 30 calendar days of the initial request, we will dismiss the grievance. Once a Tufts Health Together member or an authorized representative files a grievance, we will: Tell the member or authorized representative that we received the grievance by sending a written notice within one business day Look into and resolve the grievance within 30 calendar days from when we get the grievance Tell the member or authorized representative in writing of the outcome of the grievance, which will include the information we considered, and explain our decision Provide interpreter services, if necessary How to request a grievance decision review for Tufts Health Together members only If a member is dissatisfied with how we resolve a grievance, the member, or you as an authorized representative, may request a grievance decision review from us in the same ways that members can file a grievance, as described previously. Once a member or an authorized representative files a grievance decision review request, we will: Tell the authorized representative or the member that we received their grievance decision review request by sending them a written notice within one business day Look into the substance of the request, including any aspect of clinical care involved Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

130 Resolve the grievance decision review within 30 calendar days of getting the request and let the member or authorized representative know of the outcome in writing Document the substance of the grievance decision review request and the actions taken Provide interpreter services, if necessary MEMBER APPEALS Since the appeal process for our Tufts Health Together members differs from that for our other members, we break this information out by plan in this section. Please note: We will not take action on a member s appeal from someone other than the member unless the member signs an Authorized Representative Form selecting you or a family member, friend, or legal guardian as an authorized representative. If the member does not complete the Authorized Representative Form in a timely fashion (within 20 calendar days for Tufts Health Together members), we will dismiss the appeal. For expedited appeals, or when a member is in the hospital, we will allow the appeal process to proceed without the Authorized Representative Form. However, we do require that Tufts Health Together members complete an authorized representative form as documentation that the member had, in fact, authorized you to file the expedited appeal on the member s behalf. Tufts Health Direct appeals How to request an internal appeal A member or an authorized representative may file an internal appeal within 180 calendar days of an adverse determination. To process an internal appeal request, we require a copy of the notice of adverse determination and any additional information about the internal appeal. File an internal appeal in the following ways: Telephone call us at , Monday through Friday, from 8 a.m. to 5 p.m., excluding holidays TTY/TTD people with hearing loss can call our TTY line at , Monday through Friday, from 8 a.m. to 5 p.m., excluding holidays Mail mail a request for an internal appeal, including all documentation, to us at: Tufts Health Plan Attn: Appeal and Grievance Team P.O. Box 9194 Watertown, MA request an internal appeal by via the Contact us section of our website Fax request an internal appeal by faxing us at In person visit our office at 705 Mount Auburn Street, Watertown, MA 02472, Monday through Friday, from 8 a.m. to 5 p.m., excluding holidays Although a member or an authorized representative has 180 days to request an internal appeal, we encourage you to act as soon as possible. We will let the member and the authorized representative know that we received the internal appeal request by sending a written notice within one business day, or 48 hours, whichever is less. Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

131 Service continuation during the internal appeal process If a member files an appeal concerning the termination of ongoing coverage or treatment, we will continue the disputed coverage at our expense through the end of the appeal process as long as the member or authorized representative requests the internal appeal in a timely manner, based on the course of treatment. Ongoing coverage or treatment includes only services that we had previously authorized, and does not include services that were terminated pursuant to a specific time- or episode-related exclusion from the member s contract for benefits, unless: The treatment or proposed treatment that is the subject of the appeal is, in the opinion of the physician responsible, medically necessary A denial of coverage for such services would create substantial risk of serious harm to the patient Such risk of serious harm is so immediate that the provision of such services should not await the outcome of the appeal process Standard internal appeal time frames We will review and make a decision about internal appeal requests within 30 calendar days from the date we get the request. Any internal appeal not properly acted on by Tufts Health Public Plans within the time frames specified will be decided in the member s favor. Time limits include any extensions made by mutual written agreement between the member, or the authorized representative, and Tufts Health Public Plans. If someone tries to file an internal appeal, including an expedited appeal, and we do not already have an Authorized Representative Form for that member, we will tell the member in writing that an appeal request has been filed and will send the member an Authorized Representative Form to sign and return to us. We will take no further action until we get the signed Authorized Representative Form, unless the member is in the hospital. If the member does not send us the form, we will dismiss the request, unless it is an expedited appeal requested by a provider. Reviewing medical records as part of the internal appeal A member or an authorized representative may send us written comments, documents, or other information relating to a member s internal appeal. If we need to review additional medical records, the standard internal appeal period of 30 calendar days begins when the member or authorized representative sends us a signed authorization for release of medical records and treatment information, as required. If we do not get this authorization within 30 calendar days of our receipt of the internal appeal request, we may issue a decision on the internal appeal without reviewing some or all of the medical records. The member has a right to review their case file, which includes information such as medical records and other documents and records we considered during the appeal process. Expedited appeals If our standard time frame of 30 calendar days could seriously harm a member s life, health, or ability to get back to maximum function, or if it will cause a member severe pain that cannot be adequately managed without the requested service, then the member or authorized representative may request an expedited appeal. The member or authorized representative may request an expedited appeal from us orally, in writing, or in person rather than requesting a standard internal appeal. The member or authorized representative may also request an expedited external review from the Massachusetts Office of Patient Protection (OPP) at the same time they request an expedited appeal. Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

132 There are three situations when we may review an internal appeal in an expedited manner, and each situation has a certain time requirement in which we must decide the internal appeal: If the member is a patient in a hospital, we must issue a decision before the member is discharged from the hospital. If you tell us in writing that a delay in providing the requested service or supply would result in risk of substantial harm to the member, we must issue a decision within 48 hours. If the member is terminally ill, we must issue a decision within five business days. We will issue a decision within 48 hours, or in less time for durable medical equipment (DME), when you: Certify that the use of the DME is medically necessary Certify that a denial of coverage for such DME would create a substantial risk of serious harm to the member Certify that such risk of serious harm is so immediate that the provision of such DME should not await the outcome of the normal appeal process Describe the specific, immediate, and severe harm that will result to the member absent action within the 48-hour time period specified in 105 CMR (2) Specify a reasonable time period in which we must provide a response Any expedited appeal not properly acted on by Tufts Health Public Plans within the time limits specified will be decided in the member s favor. Time limits include any extensions made by mutual written agreement between the member, or the authorized representative, and Tufts Health Public Plans. If the expedited appeal upholds the denial of coverage of treatment regarding terminal illness, we will allow the member or the authorized representative to ask for a conference. We will schedule the conference within 10 business days of getting a request. The conference will be held within five business days of the request if the treating provider determines, after consulting with a Tufts Health Public Plans medical director, that the effectiveness of the proposed treatment or supplies, or any alternative treatment or supplies, would be greatly reduced if not provided at the earliest possible date. The member or the authorized representative can attend the conference. Written notice of appeal decisions We will notify the member and the authorized representative of our appeal decisions in writing. For adverse determinations, this notice will include a clinical explanation for the decision and will: Give specific information upon which we based the adverse determination Discuss the member s symptoms or condition, diagnosis, and the specific reasons why the evidence submitted does not meet the relevant medical review criteria Specify alternate treatment options we cover Reference and include applicable clinical practice guidelines and review criteria Let the member or authorized representative know about options to further appeal our decision, including procedures for requesting an external review and an expedited external review Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

133 External review process Members who receive a final adverse determination from us have the opportunity to file a request for an external review from the OPP. Members or their authorized representatives are responsible for starting the external review process. We will enclose an External Review Form any time we issue a final adverse determination. To start the review, the member or authorized representative must complete and submit the required form to the OPP within four months of receiving our final adverse determination. If a member has been getting a covered service and we end coverage of the service, the disputed coverage will continue at our expense through the end of the appeal process, as long as the member or authorized representative files the external review request by the end of the second business day after receiving the final adverse determination. If the external review agency decides a member should keep getting the service because there could be substantial harm if the service ends, we will keep covering the service until the external review is decided, no matter what the final external review decision is. The OPP will screen all requests for external reviews to see if they: Meet the requirements of the external review Do not involve a service or benefit we specify in the Member Handbook as excluded from coverage Result from our issuing a final adverse determination The member will not need a final adverse determination from us if we fail to act within the timelines for the internal appeal, or if the member filed for an expedited external review from the OPP and an expedited appeal from us at the same time. The OPP will screen the request for an external review within five business days of receiving the request. Once the case is deemed eligible for external review, the OPP will submit it to the external review agency. The external review agency will then send the member and the authorized representative a written decision within 60 calendar days. Expedited external reviews A member or an authorized representative may request an expedited external review if you or another provider certifies in writing to the OPP that a delay in providing the care would result in a serious threat to the member s health. The OPP will screen the request within 48 hours of receiving it. Expedited external reviews are resolved within four business days from when the external review agency gets the referral from the OPP. You may request an expedited external review at the same time you request an expedited appeal from Tufts Health Public Plans. When an external review involves our decision to end a previously authorized service If the external review involves ending ongoing coverage of services, the member or the authorized representative may apply to the OPP to keep getting the services during the external review. The member or the authorized representative needs to make the request before the end of the second business day after getting our final adverse determination. If the external review agency decides the member should keep getting the service because there could be substantial harm to the member if the service ends, we will keep covering the service until the external review is decided, no matter what the final external review decision is. Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

134 How to contact the OPP If you or your Tufts Health Direct patients have questions about member rights or the external review process, you can contact the OPP at or by fax at , or visit the OPP s website. You may also contact the OPP by at hpc.opp@state.ma.us or by mail at: Health Policy Commission Office of Patient Protection 50 Milk Street, Eighth Floor Boston, MA Tufts Health Together (MassHealth) appeals A member or an authorized representative can request an internal appeal for us to review an adverse action. MassHealth appeal rights All Tufts Health Together members and their authorized representatives have specific rights during the internal appeals process, including the right to: Make an appointment to present information in person or in writing within the internal appeal time frames Send us written comments, documents, or other information about the internal appeal Review the member s case file, including such information as medical records and other documents we considered during the internal appeal process File a grievance if we ask for more time to make an internal appeal decision and the member or the authorized representative disagrees File a grievance if we deny a request for an expedited appeal and the member or the authorized representative disagrees with that decision File directly with the BOH if we do not make an appeal decision within the required time frames (please see the following pages for specific appeal time frames) Members and their authorized representatives have the right to two levels of internal appeal for any adverse action if requesting a standard internal appeal, and one level of internal appeal if requesting an expedited appeal. Members and their authorized representatives also have the right to further appeal our decision about an upheld internal appeal decision by requesting an external review (fair hearing) through the BOH, following the process described later in the BOH section. Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

135 Requesting an internal appeal A member or an authorized representative can request a first-level internal appeal to ask that we review any adverse action, or request a second-level internal appeal to ask that we review an upheld first-level internal appeal decision. To process the request, we require a copy of the notice of adverse action for first-level internal appeals, or a copy of the first-level internal appeal decision for second-level internal appeals, and any additional information about the internal appeal. File a first-level or second-level internal appeal in the following ways: Telephone call us at , Monday through Friday, from 8 a.m. to 5 p.m., excluding holidays TTY/TTD people with hearing loss can call our TTY line at , Monday through Friday, from 8 a.m. to 5 p.m., excluding holidays Mail mail a request for an internal appeal to: Tufts Health Plan Attn: Appeal and Grievance Team P.O. Box 9194 Watertown, MA request an internal appeal by via the Contact us section of our website Fax request an internal appeal by faxing us at In person visit our office at 705 Mount Auburn Street, Watertown, MA 02472, Monday through Friday, from 8 a.m. to 5 p.m., excluding holidays Please note: If a member or an authorized representative requests an internal appeal by telephone or in person, we will request follow-up with a written internal appeal request, unless requesting an expedited appeal. If we do not receive this written documentation, we may deny the internal appeal. If we do not have enough information to make a decision about the internal appeal, we will ask the member or the authorized representative for it. If we do not get the additional information, we may deny the internal appeal. The member or the authorized representative must request an internal appeal within 30 calendar days of the notification of adverse action (or, if the authorized representative or member does not get a notice, within 30 calendar days of learning of the adverse action). The member or the authorized representative may also send us written comments, documents, or any additional information about the internal appeal. We will let the member or the authorized representative know in writing within one business day or 48 hours, whichever is less, that we received the internal appeal request. If we do not receive the internal appeal request within 30 calendar days, we will consider the adverse action final. We will dismiss internal appeals the member or the authorized representative requests after 30 days. If the member or the authorized representative believes that the internal appeal was requested on time, the member or the authorized representative has the right to request that we reverse the dismissal and continue the internal appeal. To do so, the member or the authorized representative must send a written request to us within 10 calendar days of the dismissal. We will decide whether to reverse the dismissal and continue the internal appeal. If we decide not to reverse the dismissal, the member or the authorized representative can request an external review (fair hearing) from the BOH, following the process described in the BOH section. Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

136 First-level internal appeal After looking into a first-level internal appeal, including any additional information, we will make a decision about the first-level internal appeal based on a review by a health care professional with the appropriate clinical expertise. We will make our decision within 20 calendar days of the date we get the request. If we need more information, and we expect our review to take longer than 20 calendar days, we will let the member or the authorized representative know and ask for an extension of five calendar days. At that time, we will give the member and the authorized representative a new date for us to resolve the issue. We may ask for an extension if we need more information to make a decision, if we believe the information would lead to us approving your request and if we can reasonably expect to get this information in five calendar days. If the member or the authorized representative disagrees with our decision to take an extension, the member or the authorized representative can file a grievance with us as we described previously. Also, the member or the authorized representative has the right to ask for an extension of five calendar days to give us more information. Unless the member or the authorized representative indicates to us that the member does not want to get continuing services, we will keep covering previously approved services until we decide the first-level internal appeal, as long as we get the request for a first-level internal appeal within 10 calendar days of the notice of adverse action (or, if the member or the authorized representative does not get any notice, within 10 calendar days of learning of the adverse action). If we deny the first-level internal appeal, the member may have to pay back the cost of these services. If we deny the appeal, the member or the authorized representative can request a second-level internal appeal from us. Or the member can waive the right to a second-level internal appeal and request an external review (fair hearing) directly from the BOH, following the process we describe in the BOH section. Second-level internal appeal A member or the authorized representative must request a second-level internal appeal within 30 calendar days of the date we deny the first-level internal appeal. The member or the authorized representative may also send written comments, documents, or any other information about the second-level internal appeal. If the member or the authorized representative requests the second-level internal appeal after this time frame of 30 calendar days, we will dismiss it. If the member or the authorized representative believes that they actually did file the second-level internal appeal on time, they have the right to request that we overturn the dismissal and continue the second-level internal appeal. To do so, the member or the authorized representative must submit a written request to us within 10 calendar days of the dismissal. We will decide whether to reverse the dismissal and continue the second-level internal appeal. If we decide not to overturn the dismissal, the member or the authorized representative can request an external review (fair hearing) directly from the BOH, following the process we describe in the BOH section. We will make a decision about the second-level internal appeal based on a review by a health care professional with the appropriate clinical expertise. This person will not have been involved in any prior review or determination of the appeal. We will let the member and the authorized representative know of our decision within 20 calendar days of the date we get the request. If we did not take an extension of five calendar days during the first-level internal appeal, we can do so at this time if we need more information to make a decision, if we believe the information would lead to the approval of the request and if we can reasonably expect to get the information in five calendar days. A member or an authorized representative may file a grievance if they disagree with our need for this extension. If we did use our extension during the first-level internal appeal, we are not allowed to extend the time frame of the second-level internal appeal; however, the member or the authorized representative has the right to ask for an extension of five calendar days to give us more information. Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

137 Unless a member indicates to us that they do not want to continue getting services, we will keep covering previously approved services until we make a decision about the second-level internal appeal, as long as we get the request for a second-level internal appeal within 10 calendar days from the date of our denial of the first-level internal appeal. If we deny the second-level internal appeal, the member may have to pay back the cost of these services. If we deny the second-level internal appeal, the member or the authorized representative may request an external review (fair hearing) from the BOH, following the process we describe in the BOH section. Requesting an expedited appeal The expedited appeal process exists for circumstances that involve acute medical and/or behavioral health services, and when taking the time for a standard first-level internal appeal could seriously jeopardize the member s life, health, or ability to attain, maintain, or regain maximum function. A member or an authorized representative can request an expedited appeal in any of the ways we previously described how to request an internal appeal. In addition, the member or the authorized representative may request an expedited appeal at night, on weekends, or on holidays by calling (TTY: ). The member or the authorized representative must request the expedited appeal within 30 calendar days of the notification of adverse action (or, if the member did not receive any notice, within 30 calendar days of learning of the adverse action). Unless a member indicates to us that he or she does not want to continue getting services, we will keep covering previously approved services until we make a decision about the expedited appeal, as long as we get the request within 10 calendar days of the notice of adverse action (or, if the member did not receive any notice, within 10 calendar days of learning of the adverse action). If we deny the expedited appeal, the member may have to pay back the cost of these services. If you, as a provider, file the expedited appeal request, or if you support the expedited appeal request, then we will approve the request to speed up the appeal when the request has to do with the member s health condition. We must have the Authorized Representative Form showing us that you have permission to act on the member s behalf. Please note that although we require an Authorized Representative Form giving you permission to act on the member s behalf, we will not hold up processing the expedited appeal while we wait to receive the form. If the request for an expedited appeal does not relate to a specific health condition, we may or may not decide to speed up the appeal. If we deny the expedited appeal request, we will tell the member and the authorized representative within one business day and treat the request as a standard first-level internal appeal (as we described earlier). The member or the authorized representative may file an appeal if he or she disagrees with our decision to deny the request for an expedited appeal. If we accept the expedited appeal request, we will make a decision as quickly as the member s condition requires, and in no more than 72 hours, and we will tell the member and the authorized representative of our decision by phone and in writing. If we need more information, if there is a reasonable likelihood that such information would lead to the approval of the request and we can reasonably expect to get this information in 14 calendars days, we will let the member or the authorized representative know and take a 14-calendar-day extension. The member or the authorized representative may file a grievance if they disagree with our need for this extension. The member or the authorized representative also has the right to ask for an extension of up to 14 calendar days to give us more information. Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

138 If we deny the expedited appeal, the member or the authorized representative may request an external review (fair hearing) from the BOH, following the process we describe in the BOH section. Requesting an external review (fair hearing) with the EOHHS, Office of Medicaid s Board of Hearings (BOH) A member or an authorized representative may request an external review (fair hearing) directly from the BOH after we deny a first-level internal appeal, second-level internal appeal, or expedited appeal, or if we did not resolve any of these appeals within the appropriate time frames. We will send a notice of our decision and a copy of the How to Ask for a Fair Hearing form and instructions any time we deny an internal appeal. You or the member can also call us at to get a copy of the form. The member or the authorized representative must file a request for an external review (fair hearing) within 30 calendar days from the date of our decision on the first- or second-level internal appeal. For expedited appeal denials, the member or the authorized representative must file the request within 20 calendar days from the date of our decision on the expedited appeal for the BOH to treat the appeal as expedited. If the member or the authorized representative files the request after 20 calendar days but within 30 calendar days, the BOH will treat the request as a standard external review. If the external review involves a decision by us to reduce, suspend, or terminate a member s previously approved services and you or another provider wish for the member to continue receiving the services under dispute during the external review, the BOH must receive the completed form within 10 calendar days of our decision, and the member or the authorized representative must indicate on the BOH application form that the member wants to continue getting these services. Please note that if the external review decision upholds the appeal decision, the member may be held responsible to pay back MassHealth for the cost of these services. Tufts Health Public Plans will comply with and implement the BOH decision. Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

139 MEMBER RIGHTS AND RESPONSIBILITIES We think it is important that you know our members rights and responsibilities. Our members must: Treat all health care providers with respect and dignity Keep appointments, be on time, or call if they will be late to or need to cancel an appointment Give us, their primary care provider (PCP), specialists, and other health care providers complete and correct information about their medical history, the medicine they take, and other health matters Ask for more information from their PCP and other health care providers if they do not understand what they have been told Participate with their PCP, specialists, and other health care providers to understand and help develop health-improvement plans and goals Follow care plans and instructions agreed to with their providers Understand that refusing treatment may have serious effects on their health Contact their PCP or behavioral health provider for follow-up care within 48 hours of going to the emergency room Change their PCP or behavioral health provider if not happy with their current care Voice concerns and complaints clearly Tell us if they have access to any other insurance Tell us if they suspect potential fraud and/or abuse Tell us and the state of any address, phone, or PCP changes Tell us if they are pregnant Members have the right to: Be treated with respect and dignity regardless of race, ethnicity, creed, religious belief, sexual orientation, or source of payment for care Get medically necessary treatment, including emergency care Get information about us and our services, primary care providers (PCPs), specialists, other providers, and their rights and responsibilities Have a candid discussion of appropriate or medically necessary treatment options for condition(s) regardless of cost or benefit coverage Work with their PCP, specialists, and other providers to make decisions about their health care Accept or refuse medical or surgical treatment Call their PCP s and/or behavioral health provider s office 24 hours a day, seven days a week Expect that their health care records are private and that we and you, as their providers, abide by all laws regarding confidentiality of patient records and personal information, in recognition of members rights to privacy Get a second opinion for proposed treatments and care Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

140 File a grievance to express dissatisfaction with us, their providers, or the quality of care or services they receive Appeal a denial or adverse action/determination we make for their care or services Be free from any form of restraint or seclusion used as a means of coercion, discipline, or retaliation Receive services in a culturally competent manner Get written notice of any significant and final changes to our provider network, including but not limited to PCP, specialist, hospital, and facility terminations that affect them Ask for and get copies* of their medical records, and ask that we amend or correct the records, if necessary Receive services in their covered services list or benefit and co-payment summaries Make recommendations about our member rights and responsibilities policy Ask for more information or explanation on anything included in their Member Handbook, either orally or in writing Ask for a duplicate copy of their Member Handbook at any time Ask for and get their Member Handbook and other Tufts Health Public Plans information translated into their preferred language or in their preferred format Exercise their rights without having their treatment adversely affected * Providers may charge a reasonable fee for the expense of providing copies, in compliance with 243 CMR 2.07(13)(b). The provider may not charge a fee to any Tufts Health Public Plans member if the record is requested for the purpose of supporting a claim or appeal. Privacy rights We are committed to protecting the rights and privacy of our members. Our Notice of Privacy Practices describes how we may use and disclose protected health information (PHI), and how members can get this information. Our Notice of Privacy Practices is available online, in our Member Handbooks, or by calling us at Both you, as a provider, and we are required by state and federal law (including HIPAA) to maintain the privacy of members PHI and members other personal information across our organizations, including oral, written, and electronic forms of member information. Your obligation to maintain the confidentiality of member information is also included in your provider contract. Advance directives Our members have certain rights relating to an advance directive. Advance directives are written instructions, sometimes called a living will or durable power of attorney for health care. Advance directives are recognized under Massachusetts law and make sure a person who is not capable of making a health care decision gets necessary health care. If a member is no longer able to make decisions about their health care, having an advance directive in place can help. These written instructions tell providers what to do if their patients cannot make health care decisions. We have the authority to audit Tufts Health Public Plans patients records for the presence of advance directives. Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

141 In Massachusetts, members at least 18 years old and of sound mind can make decisions for themselves. They may also choose someone else to be their health care agent or health care proxy. Their health care agent or proxy is a person who can make health care decisions for them in the event that their health care providers determine that they are unable to make their own decisions. To choose a health care agent or proxy, a patient must fill out a Health Care Proxy Form, available from you, another provider, or us. Tufts Health Public Plans patients can also request a Health Care Proxy Form from the Commonwealth of Massachusetts. Members can write to the address below and send a self-addressed stamped envelope to: Commonwealth of Massachusetts Executive Office of Elder Affairs 1 Ashburton Place, Fifth Floor Boston, MA With advance directives, members also have the right to: Make decisions about their medical care Get the same level of care as members without an advance directive and be free from any form of discrimination Get written information about their health care provider s advance directive policies Have their advance directive, if they have one, in their medical record Permissible marketing activities As a state-contracted managed care organization (MCO), we must meet MassHealth, the Health Connector, and Center for Medicare & Medicaid Services (CMS) requirements, and other applicable state and federal regulations related to member marketing activities. Marketing can have many definitions; our state contracts define marketing as: Any communication from Tufts Health Public Plans, its employees, providers, agents, or subcontractors, to an eligible member who is not enrolled in Tufts Health Public Plans and that reasonably can be interpreted as intended to influence the eligible member to enroll in Tufts Health Public Plans, or either to not enroll in, or to disenroll from, another MCO or the MassHealth Primary Care Clinician plan. This includes the production and dissemination by or on behalf of Tufts Health Public Plans of any marketing materials. Marketing shall not include any personal contact between a provider and a member who is a prospective, current, or former patient of that provider regarding the provisions, terms, or requirements of MassHealth, the Health Connector, or CMS as they relate to the treatment needs of that particular member. Our contracts define provider-site marketing as: Any activities occurring at or originating from a provider site, whereby Tufts Health Public Plans staff or designees, including physicians and office staff, personally present Tufts Health Public Plans and/or MassHealth marketing materials or other provider-site marketing materials to eligible individuals to convince them to enroll in Tufts Health Public Plans. This type of marketing also includes direct mail campaigns you send to your patients eligible for MassHealth or qualified health plans. Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

142 Our contracts also define marketing materials as: Materials that are produced in any medium, by or on behalf of Tufts Health Public Plans, and can reasonably be interpreted as intended for marketing to eligible individuals. This includes the production and dissemination by or on behalf of Tufts Health Public Plans of any promotional material or activities by any medium including, but not limited to, oral presentations and statements, community events, print media, online, audiovisual tapes, radio, television, billboards, Yellow Pages, and advertisements that explicitly or implicitly refer to MassHealth, the Health Connector, or CMS, and are targeted in any way toward eligible individuals. Our contracts require us to tell you this information and, as a contracted provider, you must comply as well. We regularly review these policies and will update you on any changes in writing. Tufts Health Public Plans and contracted Tufts Health Public Plans providers may engage in only the following marketing activities, in accordance with MassHealth, the Health Connector, and CMS requirements: Implementing state-approved targeted marketing campaigns and distributing and/or publishing approved marketing materials in our service area by Posting written marketing materials at provider sites and other locations Initiating mailing campaigns Advertising via television, radio, newspaper, websites, online, and other audio or visual advertising Sponsoring a health fair or community activity. We may conduct or participate in health fair marketing and other community activities if EOHHS or Health Connector preapprove any marketing materials we distribute We make available any free samples and gifts we offer (which will be of only a nominal value) to all event attendees, regardless of their intent to enroll in our plan Participating in state-sponsored health benefit fairs Tufts Health Public Plans and contracted Tufts Health Public Plans providers may NOT engage in the following marketing activities, in accordance with MassHealth, the Health Connector, and CMS requirements: Distributing any marketing materials EOHHS or the Health Connector does not approve Distributing any inaccurate, false, misleading, confusing, or fraudulent marketing materials, including but not limited to making any assertion or statement, whether written or oral, that The recipient of the material must enroll in our plan to obtain benefits or to not lose benefits CMS, the federal or state government, or a similar entity endorses Tufts Health Public Plans Engaging in any misleading, confusing, fraudulent marketing activities that misrepresent MassHealth, EOHHS, the Health Connector, the Health Connector, Tufts Health Public Plans, or CMS Seeking to influence a member s Tufts Health Public Plans enrollment in conjunction with the sale or offering of any non-health-insurance products (e.g., life insurance, which Tufts Health Public Plans does not offer) Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

143 Seeking to influence a member s Tufts Health Public Plans enrollment in conjunction with the sale or offering of cash, cash equivalents, or in-kind gifts Engaging directly or indirectly in door-to-door, telephonic, or any other cold-call marketing activities Conducting any provider-site marketing, except as previously discussed Engaging in marketing activities that target members on the basis of health status or future need for health care services, or which otherwise may discriminate against individuals eligible for health care services If you have any questions about the types of marketing activities you can and cannot do, please call us at and ask to speak with your provider relations representative. 5343B Tufts Health Public Plans Provider Manual CHAPTER 7: RIGHTS AND RESPONSIBILITIES

144 CHAPTER 8: Tufts Health Provider Connect Tufts Health Provider Connect is our online self-service tool that allows you to handle many administrative activities in one portal and gives you the ability to: Check member eligibility Submit claims Check claims and prior authorization status Send and receive secure messages Refer to this chapter for information about: Accessing Tufts Health Provider Connect New users If you have used Connect before but not with Tufts Health Public Plans Complete the user agreement Patient management Office management Eligibility Claims Referrals and authorizations Provider Directory Code lookup Reports File transfer agent Sending and receiving secure messages Administration References User preferences System administration Healthwise Knowledgebase Tufts Health Public Plans provider resources Referrals and Authorizations Training CareInsight Help Tufts Health Provider Connect is compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). For more information about the central enrollee record (CER) for Tufts Health Unify, please refer to Chapter 9. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

145 Accessing Tufts Health Provider Connect You can access Tufts Health Provider Connect here, from our provider home page by clicking the icon in the top right-hand corner, or by going to healthtrioconnect.com. NEW USERS If you ve never used Tufts Health Provider Connect before, begin the new user registration process. From this link: Complete the following user information screen. Click Next to enter your Office Information. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

146 After you enter all requested information, you can choose to edit it or select Finish. Note: Make sure that you do not add dashes when entering your organization s tax ID number under Office Information; please only enter the nine-digit number to register. IF YOU HAVE USED CONNECT BEFORE BUT NOT WITH TUFTS HEALTH PUBLIC PLANS Even if you are already using HealthTrio Connect through your affiliation with another health plan, you must register as a new Tufts Health Provider Connect user. From this link: Select Tufts Health Plan from the drop-down list and click Next On the User Information screen, click on the login link at the top and log in. The User Information screen will automatically populate with your information. Click Next to continue, and do the same on the Office Information screen Click Next to continue Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

147 The next screen will allow you to register additional users under the same user ID. To add staff who have already registered with Connect, select a name from the populated list in the box. Click Add User after each name. To enter staff not already registered with Connect, add their names and information in the boxes. When you are done adding staff, click Next. The next Registration Summary screen allows you to verify your information or go back and edit what you entered. If the information is correct, select Finish. If you registered for Tufts Health Provider Connect using your user ID from another health plan (so you use that user ID for both health plans), you can access Tufts Health Provider Connect after conducting transactions with the other health plan without exiting and logging in again. Simply click on the underlined role appearing to the right of the Role icon. The Role icon appears to the right of your user name at the top of any page of the site. This will take you to the Role Selection screen. Click on the Select Role button to the left of the Tufts Health Plan role. If you are experiencing difficulty logging in, please call us at or us. COMPLETE THE USER AGREEMENT After you register, please print the User Agreement from Tufts Health Provider Connect. The User Agreement must be signed by the contract signatory for your organization, who must also designate an Administrator. Complete the form along with required documentation and return it to us by fax, to , , or mail: Tufts Health Plan Attn: Tufts Health Provider Connect Accounts P.O. Box 9194 Watertown, MA Note: You must submit a completed User Agreement within 30 days of registering for Tufts Health Provider Connect or you will need to re-register. We will send you an within nine business days of receiving your signed User Agreement telling you that we have activated your account. Please print a copy of your temporary user ID and password, as instructed during the registration process. You will need this temporary ID to access Tufts Health Provider Connect for the first time. Patient management The Patient Management function allows you to confirm eligibility and view two years worth of claims and authorizations for a particular member. You can find this feature at the top on the left-hand side menu bar. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

148 With Patient Management, you can search for a member s record, select the record, and add the record to the Current Patient list so that you can easily access it. The Current Patient drop-down list: Holds up to 50 entries Automatically drops the oldest entry on the list when the number of entries exceeds 50 After adding a member to the Current Patient list, you can select him or her from the Current Patient drop-down menu and view his or her eligibility, claims, and authorization information, as shown below. To access a particular category of information Click on that category, such as Eligibility or Claims, by selecting it from the menu that appears under Patient Management. Office management With the Office Management tools, you can manage the following functions as listed on the left-hand side menu bar: Eligibility view a Tufts Health Public Plans patient s eligibility information Claims submit claims and view a claim s status Tufts Health Public Plans Provider Directory search for a provider who meets your patient s needs Code Lookup search for a diagnostic or procedure code Reports run a patient roster (panel), provider, or transaction report File Transfer Agent submit claims files electronically Preferred Drug List (PDL) view and search our current PDL Referrals & Authorizations view referral or prior authorization status Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

149 ELIGIBILITY Always verify Tufts Health Public Plans members eligibility on the date of service. We will deny claims for members who were not eligible on the date of service. To view a patient s eligibility and benefits information Click on the Eligibility function under Office Management on the left-hand side menu bar. Use the Eligibility Search function, which appears automatically, to find out if the patient is an eligible Tufts Health Public Plans member. You can search by the patient s last name, member ID (the nine-digit Tufts Health Public Plans member ID number that begins with N ), or Social Security number, as shown below. You can also search by provider to see that particular provider s patients. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

150 Search by name: Fill in the Gender and Birth Date fields to run your search if you search by name. Search by provider: Choose from the primary care provider (PCP) list to limit your search to that particular provider s patients. Click on the Search button to complete your search. The Patient Search Results table will display your search results, including all Tufts Health Public Plans members meeting your selection criteria. The results will display patients Tufts Health Public Plans member ID numbers, regardless of the search criteria you chose. Click on the name of the member for whom you wish to verify eligibility. CLAIMS Use the Claims function to: Check the status of a previously submitted claim. You can see whether we paid the claim, if it is pending, or if we denied it. Add and/or submit a CMS-1500 claim to us. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

151 To access the Claims menu Click on the Claims function under Office Management on the left-hand side menu bar. Click on the tab for the function you want to perform, either Claim Status or Add Claim. To check claim status Provide information to locate the claim, as shown in the Claim Status Search screen above. Search by claim number, patient account number, or any combination of member, provider, claim status, CMS-1500 or UB04 claim bill type, and date. Change the Date of Service Start field, as necessary. Click on the Search button. The claim you are checking may be the only one that appears, depending on how much you narrow your search. You may need to select the claim from a search results list, as shown above. Results will display patients Tufts Health Public Plans member ID numbers. To view claim details Click on the claim number (in the Claim Number column shown above) associated with the claim you want to view. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

152 The Claim Status Detail screen will appear, as shown below: To submit a batch of CMS-1500 and UB04 claims electronically Please our Electronic Data Interchange (EDI) team to test this functionality with your files first. To submit one CMS-1500 claim at a time, using the tool described below Select the Add Claim tab. Search for the member using the member ID or last name, as shown below, by providing the appropriate information. Click on the Search button. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

153 Click on the Select button to choose the appropriate member for the claim you are submitting when the Eligibility Search Results come up, as shown below. Complete the two claims entry screens. After you select the member, the first claims entry screen will appear, as shown next. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

154 Complete information for any field that has a circle to the left of it. If the Date of Current Illness or LMP is not available, use the service start date. Once you search for and select the appropriate provider s name, the Practice Name field (vendor number) and tax ID number will populate automatically. If a provider has more than one remittance address, click on his or her name and look at the Contact field to ensure you have the right remittance address for the claim. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

155 Click on the Search button to select additional codes if you need to enter multiple diagnosis codes. Helpful claims submission tips: A purple dot denotes a required field. Patient Account Number is a provider s internal number system. Any time there is a search button next to an entry box, click it for the correct input of the value. To enter modifiers, click the Search button next to the procedure code and then click Select to the left of the code. Once select is pressed, the modifier screen will pop up automatically. Click on the Add Service button when you have completed the information required for the first screen. The screen below will appear: Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

156 Complete any fields that are missing data if a screen appears that indicates you must fill in those fields. Fill in the Start Date field at the Add Claim screen with the date of service. You will need to change the date in most cases because this field automatically defaults to the day you add the claim. Fill in the Place of Service field by selecting it from the drop-down menu or typing in the industry standard number that corresponds to the place of service. You cannot submit a claim without this information. To enter procedure codes Type in the appropriate procedure code, as shown in the middle of the following screenshot. Click on the Search button to the right of the procedure code field. Select the correct procedure from the list that appears. To select modifiers If any modifiers apply to your selected procedure, you ll see a list of modifiers. Select the appropriate modifier, if required for that procedure. If the procedure does not require a modifier, you can bypass this by not selecting any modifiers and clicking Submit. Click on the Add button once you complete all the required fields. The line you entered will appear at the bottom of the screen. To add additional claim lines, enter claim line information and click on the Add button. Repeat this process until you complete adding all claim lines. Click on the Finished button, as shown on the following screen. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

157 A confirmation will now appear that shows the claim. You must click on the Submit button to submit your claim. If you want to print your claim, do so before you click Submit. To print summary information for a claim Click on the Print Claim icon (with the graphic of a small printer) in the top left-hand side of the screen. You must click on the Submit button to submit your claim. You ll receive confirmation that your claim was submitted. REFERRALS AND AUTHORIZATIONS The Referrals & Authorizations function allows you to check the status of an authorization you submitted to us, as shown next or to submit a behavioral health authorization request for outpatient services. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

158 To access the authorizations menu Click on the Referrals & Authorizations function under Office Management on the left-hand side menu bar. Click on the Status tab to check the status of a referral or authorization. To check referral or authorization status Provide information to locate the authorization. You can search by request number (the referral/authorization number we assign), or any combination of member, requesting provider, request status, and date. Change the Start Date field, as necessary. Fill in the space to the right of the field to search by request number, start date, or end date. Click on the calendar to the right of the date fields to select a date from the calendar. Click on the circle to the left of the member, requesting provider, or servicing provider information on which you want to search. Fill in the appropriate data in the space below the circle on which you clicked. Click on the Search button after you enter the appropriate information. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

159 Service requests that meet your criteria will appear under Service Request Search Results, as shown below. Click on the Service Request Number that appears in the Service Request Number column that corresponds to the particular service request on which you want to view detailed status information. To submit a behavioral health outpatient authorization request Effective August 10, 2015, the secure provider portal allows you to submit authorization requests for outpatient behavioral health services. This new self-service tool provides the benefits of submitting requests 24/7/365 and receiving an immediate approval response if the required criteria is met. This new process will be easier and more efficient for office staff and eliminates the need for faxing. (You may still submit fax requests for outpatient behavioral health services but you will not receive the benefit of an immediate response. You will be notified of the decision via faxed letter). Click on Outpatient Tab Enter required member and provider information on the Outpatient Tab ; select Psychotherapy for the requested service type and complete all fields including what services are requested (CPT code and number of units requested) Complete the Behavioral Health Referral Questionnaire prior to submitting the above information. Once the Behavioral Health Referral Questionnaire is completed, an immediate response will be displayed with either an Approved or Pended message and a confirmation number. If the request was approved, please print a copy for your records as this is your authorization number for the requested services. You will no longer receive a faxed approval letter. If the request was pended, it will be reviewed by a behavioral health clinician and you will be notified via faxed letter of the decision. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

160 Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

161 PROVIDER DIRECTORY You can search for in-network providers using the Provider Directory function under Office Management on the left-hand side menu bar. To search for a provider You can search by name or National Provider Identifier (NPI) number. You can also search by a provider s specialty, location, or contract information (network status), as shown below. Additionally, you can search by a provider s demographic information, including gender and languages the provider speaks. Type the required data in the appropriate field and/or select criteria from the appropriate drop-down menu. Click on the Search button to get your results. For details on a specific provider found in your search, click on the provider s name in the left-hand column of the Provider Search Results chart. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

162 CODE LOOKUP As shown below, you can use our Code Lookup function to search for procedure and diagnosis codes. To conduct a diagnosis or procedure code search Click on the Code Lookup function under Office Management on the left-hand side menu bar. Click on the circle to the left of either Diagnosis or Procedure to indicate the type of code on which you want to search. Fill in the data for the full or partial name of the procedure or diagnosis for which you want to obtain a code. Click on the Find button. You will get a list of search results with names similar to the procedure or diagnosis on which you searched and the affiliated ICD-9 or CPT codes. The following example shows results for a search on an appendicitis diagnosis. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

163 REPORTS The Reports function allows you to run your own reports in the format you prefer, with the data you want. You can run three types of reports, as shown below: Member Roster (Panel Report) allows PCPs to obtain a list of all members assigned to them. PCPs are only able to run member roster reports for their patients Provider Report allows you to obtain a list of providers who meet criteria you set, such as those belonging to a particular specialty Transaction Report allows you to look at the various transactions you have conducted with Tufts Health Provider Connect over a particular time frame, such as the number of submitted authorizations in the past three months To run a member roster report Click on the Reports function found under Office Management on the left-hand side menu bar. Click on the Report List tab. Click on Member Roster in the left-hand column, as shown in the previous screenshot. Next, you will see this screen: Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

164 To ensure the report has the data you need, fill in: Member use this drop-down menu to select the group of members for the report (e.g., active members, terminated members, or all members). Selection Criteria use this drop-down menu to select the type of date to search: As of view all members active on a specific date Termination effective date the date a member left Tufts Health Public Plans Added effective date the date a member joined Tufts Health Public Plans Date type in the date to select the date for the report. Click on the Calendar button to the right of the date field to select a date. Display Results use this drop-down menu to select the format (a delimited file, an MS Excel file, or a PDF). Click on the Submit button to run your report. To run a Provider Report Click on the Reports function found under Office Management on the left-hand side menu bar. Click on the Report List tab. Click on Provider Report in the left-hand column. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

165 To ensure the report has the data you need, fill in: Provider use this drop-down menu to select the desired group for the report (e.g., clinician, facility, pharmacy, or vendor). Any Specialty use this drop-down menu to indicate the specialty type to report. PCP to report PCPs, check the box to the left of PCP. Display Results use this drop-down menu to select how you want your results displayed (e.g., a delimited file, an MS Excel file, or a PDF). Click on the Submit button to run your report. To run a Transaction Report Click on the Reports function under Office Management on the left-hand side menu bar. Click on the Report List tab. Click on Transaction Report in the left-hand column. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

166 To ensure the report has the data you need, fill in: Select a Report select either transaction counts, transaction type counts, or user environment statistics at the top. Transactions to Display use this drop-down menu to indicate the transaction type to report. You can view all transactions you have completed with Tufts Health Provider Connect or you may only want to view a particular type of transaction, such as eligibility searches. Date Criteria type in the Start Date and End Date fields to indicate the time period for the report. Click on the calendar button to the right of the date fields to select a date. Display Results use this drop-down menu to select the format (e.g., a delimited file, an MS Excel file, or a PDF). Click on the Generate button to run your report. On each report screen you have the option to select batch report status. If any of the reports that you create have over 1,000 records, they will run within 24 hours. You can see the status of batch reports by clicking on the Batch Report Status tab. Once the report finishes running, you can see it within the file transfer agent, as described next. FILE TRANSFER AGENT The File Transfer Agent function allows you to retrieve secure files. To use your File Transfer Agent - Inbox Your File Transfer Agent - Inbox stores the files you download while using Tufts Health Provider Connect, as well as any files we send you. For example, if you choose to download one of the available reports, the report will automatically appear in your File Transfer Agent - Inbox. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

167 To download files to your computer Click on the File Transfer Agent function found under Office Management on the left-hand side menu bar. Click on the Inbox tab of the File Transfer Agent menu bar. Click on the phrase Download File (in the right-hand side column) that corresponds to the file you want to download to your computer. Sending and receiving secure messages On the top of every page, you ll see a Message Center link. The Tufts Health Provider Connect message center allows you to send secure messages to us and receive secure messages from us. To access your mailbox Click on the Message Center link. The following screen will appear. Use separate folders to track and store mail items, as with other online mail systems. To view a message Click on the subject name. To send a message Click on the Inbox tab, as shown below: Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

168 Click on the New Message button at the top right of the page. Use the Recipient Type drop-down menu to select the Tufts Health Public Plans team you want to send a message to (e.g., Connect assistance, provider and partner services, EDI, claims, authorizations, membership). Click on the Send Message button once you type your message. You will receive confirmation that your has been sent. To receive notification of a new message in your Inbox folder Click on the Settings button. Fill in your address in the box under Notifications (shown next) to receive external notification of s sent by us to your Inbox folder. Click on the Save button. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

169 Administration The Administration function has two primary features: User Preferences allows you to change your password and user information, and choose whether you want us to notify you when you get messages in your Inbox System Administration allows you to add a new staff member to Tufts Health Provider Connect (only your office s Tufts Health Provider Connect Office Manager can access this function) Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT

170 USER PREFERENCES To modify your user information Click on the User Preferences function under Administration on the left-hand side menu bar. Click on the User Information tab, as shown next. Type in your changes. Click on the Submit button. Tufts Health Public Plans Provider Manual CHAPTER 8: TUFTS HEALTH CONNECT