Friday, February 26, 2016

Patient responsibility in Gastroenterology services


Gastroenterology is the study, diagnosis and treatment of disorders of the digestive system. These disorders may affect the esophagus (swallowing tube), stomach, small intestine, large intestine (colon), rectum, liver, gallbladder or pancreas.

Services and subsequent payment are based on the member's benefit plan document. Providers and their office staff should use self-service channels to verify effective dates and copayments for members prior to initiating services.

Tufts Medicare Preferred HMO

Tufts Medicare Preferred HMO follows Medicare coverage guidelines. Tufts Health Plan cannot cover items and services not covered under the CMS-approved Tufts Medicare Preferred HMO benefit plan. Tufts Medicare Preferred HMO’s benefit plan currently covers a limited number of non-Medicare covered items as supplemental benefits.

Note: Supplemental benefits are subject to change each year.

Tufts Health Plan Senior Care Options

Tufts Health Plan Senior Care Options follows Medicare coverage guidelines for Medicare-covered benefits and Medicaid coverage guidelines for Medicaid-only covered benefits.


Copayments deductible and/or coinsurance may apply for commercial and Tufts Medicare Preferred HMO members pursuant to the member’s benefit plan specifics.

Note: Colonoscopies accompanied by treatment/surgery (e.g., polyp removal) may be subject to the day surgery copayment.

Tufts Health Plan Senior Care Options members have no member copayment, coinsurance or deductible responsibility.

Tufts Health Plan recommends not billing the member for the coinsurance and/or deductible amount until the claim has processed so that the appropriate member responsibility can be determined. Both the provider’s Explanation of Payment (EOP) and the Electronic Remittance Advice (ERA) will reflect the member’s responsibility amount.

Note: Tufts Health Plan will not allow the use of a so-called "waiver" to circumvent or override the provider's obligations under the applicable participation agreement with regard to services covered under the member's plan. By way of illustration and not limitation, the waiver is of no validity when applied to missed filing deadlines, provider's authorization requirements and attempts to collect payments other than applicable copayments, coinsurance or deductibles.

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