Electronic services

E-Solutions for your everyday needs

Tufts Health Plan offers a wide range of electronic solutions, including member eligibility status, benefit information, claim submission, and clinical information.

Electronic self-service tools save time and will help streamline providers' practices, reduce administrative costs, and increase information security.For technical information please refer to this user guide.

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Referral Submission and Inquiry

Providers may submit referrals electronically for members, receive a referral number upon submission, and verify the remaining number of visits using the following:

Inpatient Notification

Behavioral Health Service Requests

Request authorization for initial and continuing visits and check authorization status using Tufts Health Plan's secure Provider portal or by using the Behavioral Health IVR at 800-208-9565.

Claim Options

With electronic data interchange (EDI), providers can submit claims electronically (either directly or through a clearinghouse) and receive electronic remittance from Tufts Health Plan.

Claim Submission

For quicker payment, fewer rejections and ease of processing, providers can send their claims electronically to Tufts Health Plan using the following options:

Direct EDI Claim Submission

For direct submission, a provider's billing system is set up to connect with the claims system at Tufts Health Plan. Direct claim submission also includes support with a Tufts Health Plan EDI analyst for quick resolution of any EDI issues. There are no charges for direct claims submission.

For more information about direct EDI claim submission, call 888-880-8699, ext. 54042 or email questions to edi_operations@point32health.org.

Note: Claims submitted without a registered provider’s NPI, dental, and pharmacy claims cannot currently be submitted via EDI.

Clearinghouse Claim Submission

Tufts Health Plan accepts EDI claims from all major clearinghouses. Send one electronic file for all your claims to the clearinghouse. The clearinghouse, in turn, distributes those claims to all of the payers, including Tufts Health Plan. There is usually a fee associated with using a clearinghouse. Click here to access the EDI set-up form.

Before beginning, contact the Tufts Health Plan EDI Operations Department at 888-880-8699, ext. 54042.

Online Claim Submission

Tufts Health Plan now offers online claim submission to its providers through MD On-Line, now part of the ABILITY® Network. This option is available for professional claims only for all Tufts Health Plan products.

Providers who are already registered with MD On-Line may add Tufts Health Plan as a payer. Providers who are not yet registered should call MD On-Line at 888-499-5465 and mention that you are a Tufts Health Plan provider. All questions about registration should be directed to MD On-Line.

Note: Claims that require supporting documentation cannot be submitted electronically and providers should continue to submit these claims on paper.

Claim Status Inquiry

View both pending and processed claims as well as review message codes, payment dates, check numbers and more via the following:

Online Claim Adjustments

Providers may submit and track claim adjustments online using the Claim Status Inquiry (CSI) tool on Tufts Health Plan's secure Provider portal. The CSI tool allows providers to perform the following functions:

  • Adjust previously submitted claims, including changing provider and payee ID numbers, procedure and diagnosis codes, billed amounts, modifiers and member information.
  • Submit payment disputes by filling out an electronic form that includes the rationale for the request and allows providers to attach electronic documents for paperless submission or send supporting documents by mail.
  • Return funds by selecting either a claim refund via check or a claim to have retracted from future claim payments

Electronic Remittance Advice (ERA)

Whether claims are submitted directly, through a clearinghouse, or online through MD On-Line, Tufts Health Plan offers electronic remittance from PaySpan Health, allowing providers to automatically post payments and denials for all claims.

InterQual® Clinical Criteria and SmartSheets™

Tufts Health Plan applies InterQual criteria to certain procedures requiring prior authorization. These criteria are available on Tufts Health Plan's secure Provider portal. By logging in, providers can:

  • Review InterQual criteria for certain procedures or view a Clinical Evidence Summary
  • Access InterQual SmartSheets for submitting authorization requests to Tufts Health Plan

Clinical Quality Management (CQM) Reports

Member Health Management Reports, published monthly on the secure Provider portal, help providers track and monitor member care and manage conditions. These reports show each member's most recent date of service for key screening tests or prescriptions and are benchmarked against HEDIS® performance standards.

Eligibility and Benefits

Verify member eligibility status using the following self-service channels:

Note: Eligibility may be subject to retroactive reporting of disenrollment.

Fast, Easy and Secure. Sign Up for Electronic Funds Transfer Today!

If you are receiving paper checks, make the simple switch to electronic funds transfer (EFT) through Payspan today. Payspan provides you with easy access to your electronic remittance advice (ERAs) and Explanations of Payment (EOP), as well as:

  • Quicker access to funds — Your payments are deposited directly to your bank.
  • Greater convenience & efficiency — EFT eliminates manual processes and you don’t have to worry about lost paper checks.
  • The chance to go green — Going paperless is environmentally friendly.
  • Easy access to payment history — Track, review, and reconcile current or past payments online with Payspan’s easy-to-use payment reports.

Plus, getting signed up for electronic payments is simple!

How to Register with PaySpan Health

If you are already registered with PaySpan Health, log into your PaySpan Health account at Payspan Health and add Tufts Health Plan and/or Tufts Health Public Plans as a payer.

If you are not already registered, call PaySpan Health at 877-331-7154 for your unique registration code. Then go to Payspan Health and click the Register button.

Have your Provider ID Number (PIN), Tax ID Number (TIN), and bank routing and account number available.

A step-by-step registration guide is available through Payspan Health. For additional information, refer to the Quick Reference Guide: Electronic Funds Transfer.