Preferred Provider Organization (PPO) Plans
Tufts Health Plan’s Preferred Provider Organization (PPO) plan covers preventive and medically necessary health care services and supplies.
As a PPO member:
A deductible is the amount you must first pay out-of-pocket before any coverage is available at the out-of-network level of benefits.
Coinsurance is a percentage of the covered medical costs you are responsible for paying at the out-of-network level of benefits. You must pay coinsurance for these services until you reach the plan’s out-of-pocket maximum.
Any emergency medical care you may need is covered at the in-network level of benefits.
Sometimes when you are receiving care, your doctor may order diagnostic imaging. There are two main types: low-tech imaging and high-tech imaging.
Low-Tech Imaging—includes services such as x-rays, bone density tests, mammography, and ultrasounds. Low-tech imaging is sometimes performed in your doctor’s office or during an emergency room visit. It is covered as part of your visit and does not require a separate copayment. If your plan has a deductible, low-tech imaging services will apply toward the deductible.
High-Tech Imaging—includes CT/CTA, MRI/MRA, PET Scans, and Nuclear Cardiology. These procedures require prior authorization. This means your doctor needs to submit a request for approval before they will be covered. Many members are on a plan that has a high-tech imaging copayment. If this applies to you, this means you are responsible to pay a copayment for the procedure that is separate from your office visit or hospital copayment. Important Note: Members are exempt from paying the high-tech imaging copayment when the imaging is required as part of an active treatment plan for a cancer diagnosis. If you aren’t sure whether your plan has a high-tech imaging copayment, please check your Benefit Document or contact a Member Services Representative.
Submitting a Medical Reimbursement Claim Form
As a Tufts Health Plan PPO member, you will most likely not need to submit a request for reimbursement for medical services if you see doctors who are part of Tufts Health Plan’s provider network.
If you do receive medical care at your out-of-network level of benefits or for emergency care you receive when traveling, you can pay for the care and submit a request to Tufts Health Plan for reimbursement.
Please note that in some cases, prior authorization from an authorized reviewer may be required before you receive care from an out-of-network provider. (This does not apply to emergency care.) It is your responsibility to get prior authorization. If you don’t, the cost of the services may not be reimbursed. Always check your plan document to determine whether prior authorization is needed.
Follow these steps when submitting a reimbursement request:
- Complete a Member Reimbursement Medical Claim Form. Fill in all the required information and be sure to sign the form.
- You will need to include your proof of payment (receipt or copy of check), and an itemized bill.
- Submit to the address on the form. You can mail it to Tufts Health Plan or submit it online through your secure member account. Please note that you must submit your request within one year of receiving the service.
Member reimbursements generally take 4-6 weeks to process. Delays may happen if your form is not filled out completely and correctly, or if you don’t include the other necessary information.