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In this issue:
- Announcing the Mass General Brigham Accountable Care Organization
- Discharge notifications for providers
- MassHealth Drug List
- Medical policy updates
- Code updates
- Drug code updates
Announcing the Mass General Brigham Accountable Care Organization
We are excited to let you know that Mass General Brigham Health Plan has been chosen by the Commonwealth to be a plan for the MassHealth ACO program. This program goes live on April 1, 2023 and will uniquely support the healthcare needs of MassHealth-eligible residents of Massachusetts. In the coming months, we will be sharing additional details with you about the program. In the meantime, if you have any questions about this notice or do not want to participate in the ACO Plan, please submit your request here by February 15, 2023.
We would like to underscore that your participation in the ACO Plan will not affect your participation in other MGBHP products. Also, please note that non-MGB Primary Care Providers are not included as part of this program. We will be sending out provider education and other helpful materials as we get closer to the go-live date. In addition, you can find additional information on the program at: massgeneralbrighamhealthplan.org/providers/mgb-aco
Discharge notifications for providers
Beginning 4/1/2023, MGBHP will align with industry standards and no longer call providers for discharge dates. Providers are to notify of the plan of discharge dates via faxed census reports or the remarks section on the provider portal. Mass General Brigham Health Plan will continue to utilize Collective Medical (CMT) and Bamboo (Pt ping) census tools for updated dates of services.
MassHealth Drug List
Effective 04/01/2023, Mass General Brigham Health Plan will become fully unified with the MassHealth Drug List. As a result there are a number of coverage changes that may impact our members. You can view current MassHealth coverage on the MassHealth Drug List website.
Members who will experience a negative impact will receive letters notifying them at least 30 days prior to the change.
Response to ED boarding crisis
Mass General Brigham Health Plan will comply with regulatory guidance to ensure hospitals are reimbursed for behavioral health crisis evaluations and stabilization services provided in the Emergency Department in response to the ED boarding crisis.
This will apply to:
- Commercial members, for dates of service 11/01/2022 and forward per MA DOI Bulletin 2022-08
- MassHealth members, for dates of service 01/03/2023 and forward per EOHHS guidance issued by the Office of Behavioral Health per MCE bulletin 93
Medical policy updates
Twelve medical policies were reviewed and passed by the Mass General Brigham Health Plan’s Medical Policy Committee. These policies are now posted to MassGeneralBrighamHealthPlan.org. The table below is a summary:
|
Medical Policies |
|||
|
Policy Title |
Summary |
Products Affected |
Effective Date |
|
Reconstructive and Cosmetic Procedures |
February 2023: Annual review. The following changes were made: Page 1: Added Medicare Advantage to table. Page 1, Under Coverage Guidelines; • Removed “AllWays Health Partners reserves the right to deny coverage for any procedures that are considered cosmetic and not medically necessary.” • Clarified coverage by adding “that are altered or damaged”. • Reformatted section for clarity purposes. Criteria unchanged. Page 2: Added Gender Affirmation Medical Policy statement under Facial procedure Page 3: • Added “Prior Authorization is not required” next to both Pectus Excavatum and Carinatum subheadings. • Edited Pectus Carinatum criteria for clarity purposes. Criteria unchanged. Page 4: Added Labiaplasty criteria. Page 5: Under Scar Revision criteria, added fractional laser ablation statement. Page 7: Under Hair Removal criteria, added term “incongruence”. Page 8: Added Medicare Variation language. Also added statement regarding code list. |
All lines of business |
2/1/2023 |
|
Phototherapy and Photochemotherapy for Dermatologic Conditions |
February 2023: Annual Update. The following changes were made: · Page 1. Added Medicare Advantage to table. Added Photodynamic therapy to statement regarding table. · Page 2: Under UVA Photochemotherapy or PUVA section, added Mycosis fungoides, parapsoriasis, and pruritis. Also added “At least” to statement regarding CTCL trial. · Page 3: Under UVB Excimer Laser treating Vitiligo, added special sites to treatment area; item B. 2. Added Medicare Variation language. Added statement regarding coding applying to commercial and MassHealth plans only. ‘ · Page 5: References updated.
|
All lines of business |
2/1/2023 |
|
UVB Home Phototherapy for Skin Disease |
February 2023: Annual review. The following changes were made: · Page 1: Added Medicare Advantage language to table 1. Under Coverage Guidelines, added severe atopic dermatitis/eczema criteria. Added criteria requiring positive response and adherence to outpatient UVB phototherapy treatment. Under Documentation Requirements, added atopic dermatitis, and positive response requirement. · Page 2: Added Medicare Variation language. Added statement regarding coding applying to Commercial and Masshealth plans. · Page 3: References updated. |
All lines of business |
2/1/2023 |
|
Provenge |
February 2023: Medicare Advantage added to table. Variation language added. References updated. |
All lines of business |
2/1/2023 |
|
Lutathera |
February 2023: Annual Review. Medicare Advantage added to table. Statement regarding indications supported by NCC Compendia added. Medicare Variations language added. References updated. |
All lines of business |
2/1/2023 |
|
Tumor Treating Fields |
February 2023: Annual Review. Medicare Advantage added to table. Under Coverage Guidelines section; medical necessity language removed, and InterQual Criteria adopted. Medicare Variations language added. References updated. |
All lines of business |
2/1/2023 |
|
Carvytki |
February 2023: Annual update. Added medicare Advantage to table. Added age language under FDA-approved indication. Medicare variation language added. References updated |
All lines of business |
2/1/2023 |
|
Breyanzi |
February 2023: Annual Review. Added Medicare Advantage to table. Under Criteria section, added refractory to first-line chemo or relapse language. Medicare variation language added. References updated. |
All lines of business |
2/1/2023 |
|
Kymriah |
February 2023: Annual review. Added Medicare Advantage to table. Under Criteria, the following changes were made to align with revised MassHealth guidelines: Changed age to 26, added Philadelphia chromosome language, and added the patient must have stable and adequate kidney, liver, pulmonary, and cardiac function. Medicare Variation language added. |
All lines of business |
2/1/2023 |
|
Tecartus |
February 2023: Annual review. Added Medicare Advantage to table. Under Criteria for Initial Approval, the following changes were made to align with revised MassHealth guidelines: added “inadequate response, adverse reaction, or contraindication”, added refractory or relapsed language, added inadequate response to tyrosine kinase inhibitor criteria. Medicare variation language added. References updated. |
All lines of business |
2/1/2023 |
|
Abecma |
February 2023: Annual update. Added Medicare Advantage to table. Medicare variation language added. References updated. |
All lines of business |
2/1/2023 |
|
Yescarta |
February 2023: Annual review. Added Medicare Advantage to table. Medicare variation language added. References updated. |
All lines of business |
2/1/2023 |
In addition, as of January 2023, Mass General Brigham Health Plan customized InterQual criteria and published new guidelines.
1. CP: Imaging. The guidelines are called “Positron Emission Tomography (PET), Cardiac (Custom) - MGB
2. CP: Procedures. The guidelines are called Early Intensive Behavioral Intervention (EIBI) (Custom) - MGB
To access this criteria, providers should log in to Mass General Brigham Health Plan’s provider website at MassGeneralBrighamHealthPlan.org and click the InterQual® Criteria Lookup link under the Resources Menu.
Also, as of February 1, 2023, Mass General Brigham Health Plan has adopted InterQual criteria for its Tumor Treatment Field Therapy and will be retiring the Mass General Brigham Health Plan customized Tumor Treating Fields criteria. You will no longer find the Mass General Brigham Health Plan customized criteria on InterQual.
For more information or to download our medical policies, go to massgeneralbrighamhealthplan.org/providers/medical-policies and select the policy under the medical policy listings.
Code Updates
As a reminder to the network the following service(s) are not covered for all lines of business:
|
Code |
Description |
|
No Code |
Vibroacoustic Therapy System
|
The following service(s) previously not covered will be covered with prior authorization for Commercial and ASO lines of business only:
|
Code |
Description |
Effective Date |
|
0656T |
Vertebral body tethering, anterior; up to 7 vertebral segments |
02/01/2023 |
Drug Code Updates
The following drug(s) are now covered under the medical benefit with prior authorization all lines of business:
|
Code |
Description |
Brand Name |
Effective Date |
|
J0179 |
Injection, brolucizumab-dbll, 1 mg |
Beovu |
01/01/2023 |
The following drug(s) are now covered under the medical benefit with prior authorization for Commercial and ASO lines of business only:
|
Code |
Description |
Brand Name |
Effective Date |
|
No Specific code |
Injection, ranibizumab-eqrn, Intraocular (HCPCS J3490 can be billed to represent Cimerli Intraocular INJ until such time CMS assigns a permanent code) |
Cimerli |
01/01/2023 |
|
Q5124 |
Injection, ranibizumab-nuna, biosimilar, (Byooviz), 0.1 mg |
Byooviz |
01/01/2023 |
|
Q5126 |
Injection, bevacizumab-maly, biosimilar, (Alymsys), 10 mg |
Alymsys |
01/01/2023 |