Who is Specialist Physicians

Specialist physicians within the Tufts Medicare Preferred HMO network are expected to provide quality, cost-efficient health care to Tufts Medicare Preferred HMO members. Contracted physicians must provide care in a culturally-competent manner to all Tufts Medicare Preferred HMO members, including those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds and physical or mental disabilities.

The specialist’s primary responsibility is to provide authorized medical treatment to Tufts Medicare Preferred HMO members who have an electronic or written referral from their PCP. Services rendered without authorization or referral from their PCP, are only covered if the member received prior notice that such services will be covered. Such prior notice of coverage is the issuance of an organizational determination


If a specialist feels that additional care beyond that which has been authorized on the referral is necessary, the specialist must contact the PCP prior to rendering services that have not been expressly authorized on the referral form. If a specialist feels that additional treatment is required and cannot provide these services, the specialist must contact the member’s PCP and suggest that the PCP provide that member with an alternative referral. Tufts Health Plan will not pay for additional specialist services/treatments, including services/treatments rendered by the specialist in urgent situations.

The specialist is also responsible for submitting a summary report to the Tufts Medicare Preferred HMO member’s PCP following that member’s appointment. The summary report should be routed to the member’s PCP prior to requesting additional services.

Contracting specialists are required to provide 90 days prior notice of termination of their participation with Tufts Health Plan to Tufts Medicare Preferred HMO members who have been/are under their ongoing care.