June 18, 2012
Re: Important Change to Steward Employee Choice EPO Referral Process
Dear Provider:
I am writing to inform you that effective June 24, 2012, the referral process will change for Steward Employee
Choice EPO plan members age 19 and over. As a PCP in the Steward Employee Choice Network, it is
important for you and your office staff to be aware of these changes.
How the Referral Process Will Work (for members age 19 and over only)
Effective June 24th 2012, referrals for services with a non-Steward Employee Choice Network provider will
require review by the Steward Care Coordination Team.
•
Continue to submit referrals to providers in the Steward Employee Choice Network to Tufts Health Plan
(Note: Tufts Health Plan administers the Steward Employee Choice EPO Plan and providers in the
Steward Employee Choice Network are listed on the website: www.tuftshealthplan.com/steward).
Referrals to providers in the Steward Employee Choice Network will be automatically approved by
Tufts Health Plan and do not require a review by the Steward Care Coordination Team. Please note that
this is an administrative enhancement designed to facilitate the approval process for Steward Providers.
•
All referrals for non-Steward Employee Choice Network providers need to be submitted to the Steward
Care Coordination Team for their review. To complete the review process, you need to fill out a
Steward Referral Form and fax it to the Steward Care Coordinator at 855-676-2540.
o The Steward Referral Form is enclosed and an electronic copy is available on the Tufts Health
Plan Steward website: www.tuftshealthplan.com/steward. o Any coverage, whether partial or full, for services provided by non-Steward provider requires a
Steward Care Coordination Team referral review.
o If a request for review is not submitted, the service(s) will deny for no referral and the plan will
pay 0%. The member will be responsible for 100% of the cost of the covered service(s).
•
The Steward Care Coordination Team will determine the level of benefits for services rendered outside
the Steward Employee Choice Network, based on whether the services are available within the Steward
Employee Choice Network.
•
The Steward Care Coordinator will contact you, the non-Steward Employee Choice Network provider,
the member, and Tufts Health Plan within two to three business days with Steward’s determination as to
which level of benefits the service(s) will be paid.
•
Tufts Health Plan will process referrals according to this process.
o Please note that any electronic referrals made to non-Steward Employee Choice Network
providers will be initially rejected by Tufts Health Plan.
o When a referral to a non-Steward Employee Choice Network provider is rejected, Tufts Health
Plan will notify you immediately with HIPAA-standard rejection code 41 –
Authorization/Access Restriction.
o Upon receiving the rejection notification, you must either re-direct care by referring the member
to a Steward Employee Choice Network provider or submit a completed Steward Referral Form
to the Steward Care Coordination Team for review – as noted above.
o NOTE: You can find a Steward provider by going to the website:
www.tuftshealthplan.com/steward
Questions
If you have any questions about this change in the referral process, please contact the Steward Care Coordinator
at 855-295-4441.
Sincerely,
Charles Rollinger, M.D.
Medical Director of Steward Employee Choice Plans