Heart to Heart Winter 2017

Provider Update Winter 2017

In this issue

Referrals

Important Billing Information

Occupational Therapy Referrals

Urgent Care

Tufts Health Plan Alzheimer's Association Referrals for US Family Health Plan Members

Dear Providers,

As you know, our Heart to Heart newsletter is the primary way that we convey information to providers
in the US Family Health Plan network. The newsletter describes updates and changes to our policies, procedures, and benefits that are important to know about.

If you have any staff members who should receive Heart to Heart but aren't, please send their e-mail addresses to Stephanie ( [email protected]) or to me ( [email protected]) and we'll add them to the distribution list.

As always, thank you for caring for our uniformed services families!

Sincerely,

Billy Partain, RN
Manager, Provider Relations and Contracting

Referrals

We have recently seen an increase in referrals being written to facilities instead
of to individual providers. Referrals must be made to a network specialist who participates in US Family Health Plan and must include the number of recommended visits to the specialist. Specialist participation can be validated using the Find a Doctor search.

Questions? Please contact Stephanie or Billy.

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Important Billing Information

Do Not Bill Medicare

To avoid duplication of coverage under government-sponsored programs,
US Family Health Plan members may not use Medicare for services covered
by US Family Health Plan. Providers should only bill US Family Health Plan
for those services.

Exceptions

Medicare may be billed for services not covered by US Family Health Plan,
such as end-stage renal disease. For members with end-stage renal disease, Medicare should be billed first and then US Family Health Plan.

US Family Health Plan cannot pay any claim that has been billed first to Medicare. Providers must first reimburse Medicare for any payment made and then bill US Family Health Plan.

Except for Medicare supplements, any private insurance should be billed before US Family Health Plan, including federal and state employee insurances.

If you have questions, please contact Stephanie or Billy.

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Urgent Care

Urgent care is a benefit under TRICARE for US Family Health Plan members. Urgent care requires a referral from the Primary Care Provider (PCP). We encourage our members in our written materials to contact their PCP as soon as possible if they require urgent care services. We strongly suggest that any follow-up be done with the PCP and not at the urgent care center. Many of our PCPs are in networks that offer urgent care facilities and we encourage our members to use those facilities.

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Occupational Therapy Referrals

As of March 1, we are changing the initial number of visits approved for occupational therapy to 9 visits in order to be consistent with the benefit
for physical therapy. In the past, we have permitted PCPs to provide referrals
for up to 30 occupational therapy visits in a Plan Year (October 1 through September 30) without requiring additional authorization.

Tufts Health Plan will review requests for additional visits beyond the 9 allowed for authorization by the PCP, just as they currently do for the physical therapy benefit. There is no change in the benefit itself, only in the authorization process.

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Tufts Health Plan Alzheimer's Association Referrals

for US Family Health Plan Members

Eligible US Family Health Plan members have the benefit of the education and resource needs assessment provided by the Alzheimer's Association through its relationship with Tufts Health Plan.

US Family Health Plan members and caregivers are eligible for a referral to the Alzheimer's Association program when a member has been identified with a cognitive concern and/or a change in an existing cognitive-related condition.

Through this program, members and their caregivers may receive free consultations designed to create personalized strategies for coping with memory loss, including guidance to helpful resources in the community. If you feel that your patient and/or patient caregiver would welcome care management outreach, please contact Amy Gennaco, RN, US Family Health Plan Manager of Care Coordination at 617.562.5522 or via secure e-mail to [email protected]. Please be sure to include:

Member's name
DOB
USFHP ID #
Name of patient's caregiver/medical POA/HCP (if known)
Relationship to patient
Member or caregiver's phone #
Reason for referral
Name of referring provider and provider's contact information

If the patient and/or caregiver choose to participate in the program, you will receive a follow up from the Manager of Care Coordination.

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Provider Relations Team

Billy Partain
Provider Relations and
Contracting Manager

Stephanie Tooley
Provider Relations
Representative

617.562.5548 (office)
617.992.1882 (cell)

All of Massachusetts except Cape Cod
and the south coast.

email
617.992.1883 (cell)

All of Rhode Island, Saint Anne's Hospital, Cape Cod Hospital, and Falmouth Hospital.

Download our full hospital list