Tufts Health Plan claim options and useful notes
Tufts Health Plan Claim EDI processing helps providers to submit claims electronically – either directly or through a clearinghouse – and receive electronic remittance from Tufts Health Plan. For quicker payment, fewer rejections and ease of processing, providers can send their Tufts Health Plan claim electronically using the following electronic claim options:
Direct claim submission
- Send EDI claims directly to Tufts Health Plan and eliminate all third party interactions
- Receive the easiest and most useful claim reports that we have to offer
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 claim EDI analyst for quick resolution of any issues. There are no charges for direct claims submission.
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.
Online claim submission
Tufts Health Plan now offers online claim submission to its providers. This option is available for professional claims only for all Tufts Health Plan products. If you are already registered with MD On-Line, you can add Tufts Health Plan as a payer. All questions about registration should be directed to MD On-Line.
Claims that require supporting documentation cannot be submitted electronically and providers should continue to submit these claims as they do today.
Claim status inquiry
- Check claim status using Tufts Health Plan’s secure website, NEHEN, and NEHENNet.
- View both pending and processed claims.
- Review message codes, payment dates, check numbers and more.
Online claim adjustments
Providers can submit and track their commercial claim adjustments online using the Claim Status Inquiry (CSI) tool on Tufts Health Plan’s secure Provider website. Tufts Health Plan claims Adjustment Tool allows to perform the following functions:
- Adjust 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 your rationale for the request and allows you 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. The Tufts Health Plan 835 Companion Guide includes paid and denied claims data for both electronic and paper claims.