Navigator and Spirit Specialty Tiering Information

Tufts Health Plan will be updating the specialist office visit copayment design for Group Insurance Commission (GIC) Commonwealth of Massachusetts members enrolled in our Navigator™ and Spirit™ products as of July 1, 2014. Pursuant to the GIC plan design, Tufts Health Plan will continue to apply a three-tier approach resulting in three levels of copayments for specialists.

The following 13 specialties are designated for evaluation:

• Cardiology (non-interventional only)
• Dermatology*
• Endocrinology
• Gastroenterology* 
• Neurology*
• Obstetrics & Gynecology
• Ophthalmology*
• Orthopedics (including orthopedic hand surgeons)*
• Otolaryngology
• Pulmonology
• Rheumatology
• Surgery (general, including vascular surgeons)*
• Urology*
* Tiered on cost alone due to insufficient quality information

The following specialists will continue being classified with the not tiered or insufficient data (NT/ID) copayment level due to these sub-specialists' no longer being grouped with one of the designated specialties listed above:

  • Electrophysiologists
  • Interventional cardiologists
  • Mohs surgeons
  • Glaucoma specialists

Of the physicians who were evaluated, approximately 20% were placed in Tier 1, 65% were placed in Tier 2, and 15% were placed in Tier 3 pursuant to the GIC plan design.

Copayment Level Copayment Amount Description
Excellent (Tier 1) $25 per visit • Physicians in the selected specialties whose value rating qualified for the lower copayment
Good (Tier 2) $35 per visit • Physicians in the selected specialties whose value rating qualified for the Tier 2 copayment
Standard (Tier 3) $45 per visit • All other physicians in the selected specialties
NT/ID - Not tiered or insufficient data to evaluate $35 per visit • Physicians in the selected specialties who did not have enough resource utilization or quality data upon which to be measured, including new physicians 
• Physicians whose specialty was not selected for evaluation
PCP Copayment $20 per visit • PCPs, PCP/Specialists

In early January 2014, the physicians will be notified regarding their individual results. Tier designations were the result of an almost year-long comprehensive effort by Tufts Health Plan based on claims data from all participating GIC health plans, and aggregated by the GIC's analytic subcontractors, ViPS, Inc., and Resolution Health, Inc.

Additional Resources

Additional detail about the methodology can be found in the Tufts Health Plan Navigator™ Specialist Methodology.

For background information on Episode Treatment Groups, which are the basis for the cost-efficiency score, go to Symmetry Episode Treatment Groups® on the OptumInsight™ website. Other information and the ETG white paper Measuring Health Care with Meaningful Episodes of Care are in the Resources section of that website.

For additional detail on this methodology, please see the RHI Summary of the advanced statistical approach used in the GIC CPI Initiative.

For a complete list of RHI quality measures, please see the RHI Posting Booklet.

Requests for Review of Tier Designation

Physicians can request a review of their tier designation by completing and submitting the online Physician Tier Designation Review form , or by completing the Physician Tier Designation Request for Review  and submitting that completed form to Tufts Health Plan by:

  • E-mail to
  • Fax to 617-673-0999, Attn: Navigator Validation Team
  • Mail to Tufts Health Plan, Mail Stop 15-LH, 705 Mount Auburn Street, Watertown, MA 02472

All requests for review should clearly state the basis for the request and include any information that supports the physician’s reasons for believing that the tier designation is in error.

January 8, 2014
Updated: March 24, 2014
Updated: August 22, 2014

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