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					                                                                                          Tufts Medicare Preferred Provider Manual




Authorizations

Referral Authorizations
The Referral Authorization Request Form must be used to refer Tufts Health Plan Medicare Preferred HMO Members to
specialty providers. This form demonstrates that the medical group has authorized the services indicated and allows the
Tufts Medicare Preferred HMO Claims Department to reimburse the provider for services rendered. Internal referral
management ensures that specialty care is provided only when medically appropriate and authorized by the medical
group except in cases where the Member may self-refer for services.
Note: Each medical group may determine its internal referral management process. Medical groups may choose to
      monitor utilization via the referral form or use a log system as a tracking mechanism.
The following care and services require referral authorizations for claims payment:

 •   Professional services in an outpatient setting of a clinic or hospital (excluding emergency services and urgently needed
     care).
 •   Outpatient contracted providers specialty care (excluding yearly routine eye care, routine OB/GYN services, mammograms,
     influenza, pneumococcal and hepatitis B vaccines, and services specified in a treatment plan) needed to treat serious and
     complex medical conditions.
 •   All non-contracted provider care (excluding emergency services, urgently needed care and renal dialysis services).



Out-of-Area Services
Tufts Medicare Preferred HMO provides coverage without authorization to Members if they require emergency or
urgently needed services, and also covers post stabilization services provided after an emergency to either maintain the
stabilized condition or, under certain circumstances, improve or resolve the Member's condition. Post stabilization
services are covered until one of the following occurs:

 •   The Member is discharged (see Financial Programs).
 •   A contracting medical provider assumes responsibility for the Member’s care.
 •   A contracting medical provider with privileges at the treating facility assumes responsibility for the Member's care.
 •   The non-contracting medical provider and Tufts Medicare Preferred HMO agree to other arrangements.

In some cases Members may be directed from an out-of-area provider to return to the out-of-area provider for a
non-urgent or non-emergent follow-up visit. Any care outside of the Tufts Medicare Preferred HMO service area
authorized by the medical group is the financial responsibility of the medical group.


Referral Authorization Process — Tufts Medicare Preferred HMO
To ensure that appropriate specialty care is provided when medically necessary, the primary care provider (PCP)
initiates and coordinates the referral management process as outlined in the following list:




Tufts Health Plan Medicare Preferred                                                                                             1
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•   The PCP can authorize a standing referral authorization to a specialist in the Tufts Health Plan network indicating the spe-
    cific services and number of visits to be provided to the Member when:
    - The PCP decides that such a referral authorization is medically necessary.
    - The specialist agrees to a treatment plan and provides the PCP with all necessary clinical and administrative information
      on a regular basis.
    - The health care services to be provided are consistent with the terms of the Member’s benefit document.
•   If the PCP is writing a referral to a non-contracted provider, the non-contracted provider must be participating with Medi-
    care.
•   Specialists must submit a summary report on a timely basis to the medical group following the Member’s appointment.
•   Any questions or problems regarding the referral authorization form should be directed to Tufts Medicare Preferred HMO
    Provider Relations at 1-800-279-9022.
•   PCPs should not generate referral authorizations for urgent/emergency services. PCPs should contact the case manager (CM)
    to notify Tufts Medicare Preferred HMO of out-of-area care at 1-888-766-9818.
•   Any non-urgent or non-emergent outpatient care outside the Tufts Medicare Preferred HMO service area reported to the case
    manager and authorized by Tufts Medicare Preferred HMO is the financial responsibility of Tufts Medicare Preferred HMO;
    if authorized by the medical group, care is the financial responsibility of the group.
•   Any outpatient care outside the Tufts Medicare Preferred HMO service area (other than urgent or emergent care or renal
    dialysis services) requires approval by the PCP.
•   If a contracting specialist provides a service without a referral authorization from the Member’s PCP, the claim will be sent
    to the PCP for review and will be released for payment unless the PCP authorizes denial of payment.


Notice of Financial Responsibility
Tufts Medicare Preferred HMO policy specifies that Members are responsible for obtaining referral authorizations for
those services that require a referral. Contracting specialists have the right to bill Members who fail to obtain a referral
authorization after the claim has been denied by Tufts Medicare Preferred HMO if the Member has signed a waiver
regarding the services. For clarification of the procedures that contracting providers and facilities should follow prior
to rendering care to Tufts Medicare Preferred HMO Members, see the Referral/Authorization Waiver Requirement.
To confirm understanding of Tufts Medicare Preferred HMO policy, patients must sign the Notice of Financial Liability
that notifies Members in advance that they may be financially responsible for the service. Contracting specialists
cannot hold Members responsible for payment without having a signed copy of this notice.

Referral Report
On a weekly basis, Tufts Medicare Preferred HMO sends PCPs the 10-day business report listing all outstanding
claims that are pending for referral/authorization (see the sample Notice of Attestation of Authorization and Denial of
Payment and Business Report — Claims Report for All Referrals Pending). Providers have the opportunity to authorize or
deny claims payment based on this information.
If providers deny payment of the service, they must send their response to Tufts Medicare Preferred HMO within 10
business days of receipt of the report for proper adjudication of the claim, which meets the CMS clean claims
requirement of within 30 days of the claim receipt date.
The Notice of Attestation of Authorization and Denial of Payment must accompany the report and must include a valid
reason for a denial. The form must be signed and dated by the Member’s PCP, a covering physician, or the medical
director. Note that a stamped signature is not appropriate. After 10 business days, any claims for which a response is
not received are considered authorized.




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The acceptable responses that can be returned on the report are:

 •   Member Self-Referred, Medical Documentation Reviewed, Non-Urgent / Non-Emergent.
 •   Referral authorization on file is exhausted (dates/visits), or
 •   Other (must be specified).

If Tufts Medicare Preferred HMO does not receive a response from a provider within 10 business days of receipt of the
report, the claims listed on the report will be adjudicated for payment on the 11th day.


Completing the Referral Authorization Request Form
The Referral Authorization Request Form requires information about the PCP, the patient, and the consulting provider. The
following steps are required to complete the referral authorization request process:

 1. The PCP must complete the Referral Authorization Request Form with the required information as shown in the following
    sections:
     •   Primary Care Provider Information.
     •   Patient Information.
     •   Consulting Provider Information.
     Note: If any required fields are left blank, the form will be returned to the PCP for missing information.
 2. The PCP distributes copies of the form as follows:
     •   White copy to Tufts Medicare Preferred HMO as indicated in the Tufts Health Plan Claims Submission Guidelines.
     •   Canary copy to the specialty provider.
     •   Pink copy for the PCP’s files.
     •   Goldenrod copy to the patient.
     • The Tufts Medicare Preferred HMO Claims Department receives the form and enters the referral
       authorization in the system.
 3. Tufts Medicare Preferred HMO Reviewers check the date of service on the referral authorization and attach the matching
    claim for adjudication.
 4. For claims with no matching referral authorization, Tufts Medicare Preferred HMO Analysts investigate. If no matching
    referral authorization is found, Analysts hold the claim for AUREQ: Authorization/Referral Required; REFEX: Referral on
    file has been exhausted; or REFPD: referral on file does not match provider and/or group.
 5. The Tufts Medicare Preferred HMO Claims Department sends the Tufts Medicare Preferred HMO Claims Report (listing all
    referral authorization-pending outpatient physician, home health and custodial claims) to medical groups for their response
    to either authorize or deny payment of the service.


Primary Care Provider Information
Include the following:

 •   Provider name (first and last).
 •   Provider ID number and/or NPI (National Provider Identifier).
 •   Date service was requested.
 •   Date determination was made.
 •   Date prepared.
 •   Name of preparer.
 •   PCP signature.
 Note: All information is required. Otherwise, the referral authorization form may be returned to the PCP with a cover sheet
          requesting additional information.



Tufts Health Plan Medicare Preferred                                                                                              3
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Patient Information
Include the following:

    •   Name of patient.
    •   Patient ID number.
    •   Date of birth.
    •   Telephone number.
    •   Reason for referral/diagnosis.
    Note: Patient name, ID number, and date of birth are required for authorization and claim payment.
    Patient information is available from the following sources:
    •   Member ID card.
    •   Tufts Medicare Preferred HMO Individual Election Form.
    •   Tufts Medicare Preferred HMO Provider Relations Department at 1-800-279-9022.
    •   Tufts Medicare Preferred HMO Monthly Eligibility Listing Report.
    •   Tufts Health Plan Web site.
    •   Point of Service (POS) device.
    •   Integrated Voice Response (IVR) system.


Consulting Provider Information
Include the following:

•       Consulting provider name (first and last).
•       Consulting provider ID number and/or NPI (National Provider Identifier).
•       Address.
•       Telephone number (optional).
•       Specialty group name and ID number, if applicable.
Circle the appropriate Setting of Care abbreviation:
•       OFF = Office
•       SDC = Surgical Day Care
•       OPD = Outpatient Department
•       OTHER = Specify


Requested Service
You must enter a general procedure description or CPT/HCPCS codes for specific procedures. Use of CPT/HCPCS
codes is optional when procedure is not specified.

•       Evaluation ONLY (1 visit).
•       Second Opinion (1 visit).
•       Evaluation and Treatment, Authorizes Hospitalization or Ambulatory Procedures (1 visit).
•       Evaluation/Treatment/Follow-up (2 visits), Authorizes Hospitalization or Ambulatory Procedures.
•       Multiple Visits (indicate number).
•       Restricted Authorization/FOR SPECIFIC PROCEDURE(S) ONLY.
•       Enter the procedure(s) name, and/or use the CPT/HCPCS codes.
Notes
• The referral authorization is valid for one year if no time frame is specified.
•       The type of service must be marked to identify authorized visits. Otherwise, the referral authorization will default to one
        visit.


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Information from PCP to Accompany Referral Authorization
Enter the reason for the referral authorization and the primary diagnosis.

To Consulting Specialty Provider
This is a preprinted reminder to the consulting provider. No action is required by the referring office.

Physician Group Use Only
This field is for the medical group’s internal use. The Member is authorized for treatment after the Utilization
Management (UM) Committee has reviewed, approved and completed this section. It is not required for claim
payment.

Distribution
If the PCP office does not submit referral authorizations electronically, the PCP office is responsible for distributing
the four copies of the referral authorization form as follows:
     White:         Tufts Medicare Preferred HMO
     Canary:        Specialty Provider
     Pink:          Primary Care Provider
     Goldenrod:     Patient


Electronic Referral Authorization Exclusions
Tufts Medicare Preferred HMO referral authorization policies apply to electronic referrals. However, certain services
and/or specialties do not require referral authorizations, or they require alternative prior authorization or
preregistration. Referral authorizations for the following should not be submitted electronically:

 •     Mental health/substance abuse.
 •     Admission to any facility.
 •     Home care / durable medical equipment.
 •     Visiting Nurse Association (VNA).
 •     Oral surgeon, group or clinic.
 •     Community health center.
 •     Social worker / group.
 •     Ambulance services.
 •     Clinical specialist / group.
 •     Hospice provider.
 •     Home rehab / skilled nursing facility.
 •     Out-of-plan services.




Tufts Health Plan Medicare Preferred                                                                                       5
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Services Not Requiring a Referral Authorization
Services not requiring a referral or prior authorization include the following:

•   Emergency services: Covered inpatient or outpatient services that are furnished by an in-plan or out-of-plan provider who is
    qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition.
    Emergency medical conditions manifest themselves by acute symptoms of sufficient severity (including severe pain) such
    that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of imme-
    diate medical attention to result in (1) serious jeopardy to the health of the individual or, in the case of a pregnant woman, the
    health of the woman or her unborn child, (2) serious impairment to bodily functions, or (3) serious dysfunction of any bodily
    organ or part.
•   Urgently needed services: Covered services provided when a Member is temporarily absent from the Medicare Advantage
    plan’s service area when such services are medically necessary and immediately required (1) as a result of unforeseen ill-
    ness, injury, or condition, and (2) it was not reasonable given the circumstances to obtain the services through the organiza-
    tion offering the Medicare Advantage plan.
•   Routine care by plan providers:
    - OB/GYN care by in-plan providers (care including but not limited to mammography screening, pap smears, pelvic and
      breast exams).
    - Hearing and vision exams.
    - Colorectal and prostate screening exams.
•   Observation care: Care by an attending physician who admits a patient for observation, or care by a physician who is con-
    sulting for a patient in observation.
•   Certain vaccines administered by plan providers (for example, influenza, pneumococcal, and hepatitis B vaccines).
•   Renal dialysis services.
•   Qualifying clinical trials: Original Medicare covers routine costs of qualifying clinical trials. The Member is responsible
    for paying an Original Medicare cost-sharing amount for these services. A Member does not need to obtain a referral
    authorization to join a clinical trial and is not required to see in-network providers. However, it is recommended that the
    Member inform Tufts Medicare Preferred HMO before he or she starts a clinical trial. That way, Tufts Medicare Preferred
    HMO can keep track of the Member’s health care services. Further information regarding clinical trials is included in these
    publications:
    - Medicare Clinical Trial Policies.
    - Medicare National Coverage Determination Manual, Chapter 1, Part 4, Section 310.1, "Routine Costs in Clinical Trials."
    - Tufts Medicare Preferred HMO Evidence of Coverage (EOC).




Special Authorization Rules
Medicare-Approved Facility Requirement
Medicare has issued several national coverage determinations (NCDs) providing coverage for services and procedures
of a complex nature, with the stipulation that the facilities providing these services meet certain criteria. These criteria
usually require, in part, that the facilities meet minimum standards to ensure the safety of beneficiaries receiving these
services. Certification as a Medicare-approved facility is required for performing the following procedures. See the
Medicare National Coverage Determination Manual (NCD manual) for coverage criteria:

•   Lung volume reduction surgery: NCD manual, Section 240.
•   Carotid artery stenting (CAS) with embolic protection: NCD manual, Section 20.7.
    Note that this requirement does not apply to CAS performed in a Medicare-covered Category B IDE study or post-approval
    study.
•   Ventricular Assist Device (VAD) destination therapy: NCD manual, Section 20.9.
•   Bariatric surgery: NCD manual, Section 100.1.


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In addition to these procedures, there is also a long-standing requirement that all heart, heart-lung, liver,
intestinal/multivisceral, kidney, and pancreas transplants be performed at a Medicare-approved facility. The transplant
work-up evaluation must also be performed in a Medicare-approved transplant facility.
Refer to the following information in CMS to determine if a facility is Medicare-approved to perform a particular
service.

 •   LVRS, bariatric surgery, carotid artery stenting with embolic protection, and VAD as destination therapy:
     See http://www.cms.hhs.gov/MedicareApprovedFacilitie/
 •   Heart, heart-lung, lung, liver, and intestinal transplants:
     See http://www.cms.hhs.gov/ApprovedTransplantCenters/
 •   Kidney and pancreas transplants:
     See http://www.cms.hhs.gov/ESRDGeneralInformation/02_Data.asp#TopOfPage

Not all Tufts Medicare Preferred contracted providers who perform these services are Medicare-approved. Tufts
Medicare Preferred will not pay for services rendered at a non-Medicare-approved facility and contracted providers
cannot hold the Member liable for these services.
For a listing of Medicare-approved facilities that are also contracted with Tufts Medicare Preferred for each of the
services above, refer to the Tufts Health Plan Medicare Preferred Medicare Approved Facilities document, available on the
Tufts Health Plan Web site at www.tuftshealthplan.com.
In addition to the Medicare-approved facility requirement, all plan precertification, authorization, in-network and
out-of-network plan rules apply. Medical groups must be sure Members are referred only to Medicare-approved
facilities for these services. To the extent a medical group/PCP is involved in referring a Member to a
non-Medicare-approved facility, the medical group will be financially liable for the associated costs. Because these
services must be provided in a Medicare-approved facility to be covered, the costs of services in a
non-Medicare-approved facility cannot be paid using Medicare funds.


Home Care Authorization Policy
Authorization for home care services by delegated medical groups must be noted on the Home Care/DME Log and
submitted to the Tufts Medicare Preferred HMO Claims Operations Department to ensure claims payment.
Authorizations for non-delegated groups are entered directly into the case management documentation system by the
case management department after authorization by the Tufts Medicare Preferred case manager.
Tufts Medicare Preferred case managers and delegated case managers are instructed to use the Medicare coverage
criteria as well as the Tufts Medicare Preferred HMO Evidence of Coverage (EOC) to determine benefit coverage for
these services. Authorizations are reviewed with the PCP/group medical director as needed to make final coverage
decisions.
To submit referrals/authorization in hardcopy format using the Tufts Medicare Preferred HMO Medical Group Homecare
Authorization Log (available at www.tuftshealthplan.com/providers), the following procedures must be followed:

 •   The case manager is responsible for completing the Homecare Authorization Log.
 •   The log must be legible (typed forms and printouts are preferred).
 •   Updated logs are submitted to the Tufts Medicare Preferred HMO Claims Operations supervisor, at least weekly, to enter
     into the claims system for payment.
 •   All fields must be completed.

On a daily basis, Tufts Medicare Preferred HMO Claims may send requests to the Tufts Medicare Preferred case
manager or delegated case manager regarding homecare services, because Tufts Medicare Preferred was unable to
identify an authorization for such services, or the authorization on file does not cover all services.



Tufts Health Plan Medicare Preferred                                                                                           7
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Delegated case managers will receive a Delegated Medical Group Authorization Form that gives the medical group the
opportunity to authorize or deny claims payment.

•   If payment of a service is denied, this denial must be sent to Tufts Medicare Preferred HMO within 10 business days of
    receipt of the form for proper adjudication of the claim, which meets the CMS clean claims requirement of within 30 days of
    the claim receipt date.
•   If Tufts Medicare Preferred HMO does not receive a response within 10 business days of receipt of form, the claim will be
    paid on the 11th business day.

Non-delegated case managers will receive such requests through established internal Tufts Health Plan communication
methods.


Medications Covered by Original Medicare
Tufts Medicare Preferred covers all drugs covered by Original Medicare.
Note: Medications covered by Original Medicare are not part of the Member’s Part D prescription drug benefit.
Original Medicare-covered medications include the following:

•   Drugs that usually are not self-administered by the Member and are injected while receiving physician services.
    For additional information, see the Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Ser-
    vices, Section 50.2, "Determining Self-Administration of Drug or Biological."
•   Drugs Members take using durable medical equipment (such as nebulizers) that were authorized by Tufts Medicare Pre-
    ferred HMO.
•   Clotting factors Members give themselves by injection if they have hemophilia.
•   Immunosuppressive drugs, if the Member had an organ transplant that was covered by Medicare. The Member is responsible
    for 20% of the Medicare-approved charge for covered immunosuppressive drugs.
•   Injectable osteoporosis drugs, if the Member is homebound, has a bone fracture that a doctor certifies was related to
    post-menopausal osteoporosis, and cannot self-administer the drug.
•   Antigens.
•   Certain oral anti-cancer drugs and anti-nausea drugs.
•   Certain drugs for home dialysis, including heparin, the antidote for heparin when medically necessary, topical anesthetics,
    Erythropoietin (Epogen) or Epoetin alpha, and Darboetin Alpha (Aranesp).
•   Intravenous Immune Globulin (IVIG) for the treatment of primary immune deficiency disease in the Member's home.



Additional Drug Coverage
Other outpatient prescription drugs are covered by Tufts Medicare Preferred HMO, such as antibiotics and high blood
pressure medication for Members enrolled for Medicare Prescription Drug Coverage. This benefit is explained in
Section 6 of the Tufts Medicare Preferred HMO Evidence of Coverage (EOC). This section also includes information
about which drugs are not covered under this benefit.


Pharmacy Medical Review Requests
If you are requesting a formulary or tiering exception for a Member, you must provide a statement to support your
request. You can submit the request using the Tufts Health Plan Universal Pharmacy Medical Review Request Form or the
Medicare Part D Coverage Determination Request Form, available at www.tuftshealthplan.com.




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The form requests information regarding diagnosis and what other drug, if any, has been prescribed for the diagnosis
and why it has not worked. You can submit the form in two ways:

 •   Fax the completed form to: 1-617-972-9409
 •   Mail the completed form to:
     Tufts Medicare Preferred
     705 Mount Auburn Street
     Watertown, MA 02472
     Attention: Precertification Department

You can also provide an oral supporting statement by calling Tufts Health Plan Medicare Preferred Provider Relations
at 1-800-701-9000 (TDD 1-800-208-9562), Monday - Friday, 8:00 a.m. - 8:00 p.m.
Standard review requests must be made within 72 hours from the time the Tufts Medicare Preferred Precertification
Department receives the request with supporting statement from the prescribing provider.
Expedited review requests must be made within 24 hours from the time the Tufts Medicare Preferred Precertification
Department receives the request with supporting statement from the prescribing physician.
Tufts Health Plan’s Precertification Department reviews the information submitted on the request form and can either
approve or deny the request. If the Precertification Department denies the request, the Member can appeal the decision.
For additional information about Member appeals, see Grievances, Organization Determinations, and Appeals.


Support Documents
The following sample documents (such as forms, letters, policies, reports) support the information in this chapter.
• Referral Authorization Request Form
• Notice of Attestation of Authorization and Denial of Payment
• Business Report — Claims Report for All Referrals Pending
• Delegated Medical Group Authorization Form




Tufts Health Plan Medicare Preferred                                                                                   9
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Figure 1:      Referral Authorization Request Form




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Figure 2:       Notice of Attestation of Authorization and Denial of Payment




Tufts Health Plan Medicare Preferred                                                                           11
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Figure 3:       Business Report — Claims Report for All Referrals Pending




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Figure 4:       Delegated Medical Group Authorization Form




Tufts Health Plan Medicare Preferred                                                              13
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                                     Chapter last updated 01/2010. Revision dates may not be reflective of actual policy changes.
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