Providers are compensated according to Tufts Health Plan network contracted rates regardless of the address where the service is rendered. Claims are subject to payment edits that are updated at regular intervals and generally based on Centers for Medicare & Medicaid Services (CMS), specialty society guidelines, drug manufacturers’ package label inserts and National Correct Coding Initiative (CCI).

Procedure Code Guidelines

Tufts Health Plan will not compensate for inappropriately-coded services, based on Procedure  code /HCPCS Procedure Code Guidelines.

Compensation for providers who are not radiologists is based on privileging requirements. Claims received for services that do not meet privileging requirements will be denied and the member is not responsible for payment. Tufts Health Plan does not compensate for any component of MRI/MRA, CT/CTA, and PET services performed by a participating physician who is not credentialed by Tufts Health Plan as a radiologist.

Diagnostic and Radiology Services
Tufts Health Plan will not compensate a diagnostic test or radiology service billed with modifier 26 (professional component) and modifier TC (technical component) if the technical and professional components of the service are performed by the same provider billed on the same or different claim on the same date of service. According to the AMA Principles of Procedure Coding, it is not appropriate to report the components of the professional and technical service separately.

Tufts Health Plan will not compensate for the professional component (modifier 26) or consultation (76140) when billed with a radiology procedure performed in the office setting and in conjunction with an E&M service.

Tufts Health Plan will not compensate professional services when billed by a provider other than an anesthesiologist, neurologist, physical medicine specialist, radiologist or radiation oncologist in the inpatient, outpatient or ER setting.

Compensation/Reimbursement for Multiple Imaging Procedures

A reduction in payment is applied to claims submitted for the technical (performance of the imaging service) or global (performance and interpretation) component of an imaging procedure when certain procedure code combinations are billed for a single member within the same visit.

In these instances, Tufts Health Plan will compensate the imaging service with the higher allowable compensation amount at 100% of the Tufts Health Plan compensation rate and subsequent procedure(s) that are subject to reduction logic will be compensated at 50% of the Tufts Health Plan compensation rate.