Resources and Forms for Employer Groups

I Have a Plan to Take Care of My Employees - Find out why Tufts Health Plan is the right choice for your business

Member Enrollment Materials
Member Enrollment Kits include a member brochure, member application, mail order pharmacy information, member discount flyer, and service area map.

Just Need an Application?

Brochures

Specific Plan Design Information

Electronic Enrollment
We offer employers the ability to send member enrollment data directly from their human resources system to our system through secure electronic processes. Please reference the EDI Enrollment and Reconciliation Guide for greater detail or contact 888-880-8699, ext. 4030 for more information.

Employers can also send us enrollment data electronically using the 834 Benefit Enrollment and Maintenance Transaction. Please reference the 834 Companion Document and the 834 Reference Guide for more information. And, if you have any questions regarding the translation of HIPAA values into Tufts Health Plan proprietary values, please view the 834 Submitter Aide.

In addition to EDI Enrollment, Tufts Health Plan also offers Web Enrollment. This option provides the User the ability to enroll employees and perform plan administration online. Web Enrollment functionality is available by registering here.

Change Senior Access Administrator Form - This form can be faxed or mailed. Instructions are listed on the form for your convenience.

Tufts Health eAccess Materials
Tufts Health eAccess is Tufts Health Plan's technology offering for providers, employers and brokers, and members. These materials provide important information about ways to save you time and money using state-of-the-art technology.

Fact Sheets on:
- Electronic Enrollment
  - Web Enrollment
  - Electronic Data Interchange (EDI)
- Web Roster
- Employer Web Reporting
- Online Billing
- Tufts Health Plan Employer Web site content

Employer Group Applications

Large Group Application: for groups with more than 51 eligible employees
Small Group Application: for groups with 10 to 50 eligible employees

Administrative Manuals

Member Change Form

Member Change Form for all products

Claim Forms

Caremark Claim Form: to obtain reimbursement for prescription costs paid out of pocket.
Caremark Foreign Claim Form: to obtain reimbursement for prescription costs paid out of pocket while outside the United States.
Member Reimbursement Medical Claim Form: cover letter, help sheet, and medical claim form for all HMO, POS, EPO, PPO, and CareLink members with the Tufts Health Plan network
Claim Form for PPO members with the PHCS provider network

Dependent Certification Forms: to verify the full-time student status of covered dependents over the age of 19.

Dependent Certification Form
Dependent Certification Form (Spanish)
Disabled Dependent Evaluation Form to be filled out by the member and his or her physician.
Massachusetts Continuation of Coverage (for groups with 2-19 employees)

Group Retiree Plan Documents

Miscellaneous Forms and Information