April 2024 - Behavioral Health Resources for PCPs, Improving Call Wait Times

Building trust with patients who have autism


Building trust takes time with every patient. But given that April is Autism Acceptance Month, it’s a great time to raise awareness of how far that trust can go with individuals on the spectrum. Building trust with patients who are autistic requires additional strategies. The good news is that those efforts can be significant in establishing better communication and care. Read the full article.



MGBHP Provider Service Team assists our Provider Community with the following inquiries:
•    General questions around provider participation status
•    Member benefits
•    Claim request for review/ appeals
•    Authorization requirements/ escalations
•    Medical drug specialties 
•    Other inquiries related to MGBHP policies and procedures  
Phone:  855-444-4647
Email: HealthPlanProvidersService@mgb.org 

MGBHP Provider Relations works in partnership with provider offices to build and maintain positive working relationships and respond to the needs of contracted providers and assist with any training and education needs. Provider Relations can also assist with escalations. 
Email: HealthPlanProvRelations@mgb.org 

Provider Portal - Register for the portal to complete the following tasks:

•   Benefits and cost sharing 
•   Claims Status
•   Member Eligibility
•   PCP Changes
•   Authorization Submission
•   EOP
•   And more

Register and access the portal here: https://provider.massgeneralbrighamhealthplan.org/ 


In this issue:

Responding to the Change Healthcare cybersecurity incident

Mass General Brigham Health Plan continues to monitor the Change Healthcare cybersecurity incident and assess any impact to our business processes for providers.

At this time, providers can continue all business processes with Mass General Brigham Health Plan. After Change Healthcare suspended access to its systems in response to the incident, we resumed payments to providers through alternative processes. In addition, providers can submit claims, check member eligibility and benefits, and request prior authorizations and referrals. Providers that are experiencing any challenges with claims submission through standard channels can also submit claims through an alternative clearinghouse or by mail using the address on the back of our member ID card.

We are committed to providing updates as information becomes available from Change Healthcare. For the latest information about the Change Healthcare incident, you can visit the dedicated incident webpage.


Improving call wait times

We understand there are longer than normal wait times when contacting the Provider Call Center. Our leadership team is working diligently to recruit and train additional staff to keep up with the demands in volume.  We appreciate your understanding and cooperation. Please use our Provider Portal to answer routine inquiries such as benefits and cost sharing, claims status, eligibility, explanation of payments, authorization, outpatient code checker tool, and much more.  Our provider call center hours of Operation are 8:00 AM to 4:30 PM Monday- Friday (closed daily from 12:00 PM-12:45 PM and Wednesdays from 9:30 AM-10:30 AM). You can also contact us through our provider email address at HealthPlanProvidersService@mgb.org.


ACO Spotlight: Provider’s Role in Improving ACO Quality Measures

What’s New? MassHealth ACO Quality and Equity Incentive Program (AQEIP) and 1115 Waiver

Starting in April 2023, Mass General Brigham Health Plan (MGBHP) received approval to support Mass General Brigham’s Accountable Care Organization (ACO) through the state’s re-procurement process under the Centers for Medicare and Medicaid Services (CMS) 1115 waiver.

MassHealth’s Accountable Care Organizations (ACOs) are incentivized through the Quality and Equity Incentive Program (AQEIP) to pursue performance improvements in three domains: demographic and health-related social needs data, equitable quality and access, and capacity and collaboration.

At MGBHP, the Quality Department has spearheaded performance improvement in collaboration with provider partners in all three domains and is pursuing NCQA Health Equity accreditation by January 2026.

The ACO Quality Measures that are part of MassHealth AQEIP include claims-based measures, clinical quality measures, and member experience surveys. For calendar year 2024, MGBHP has identified the following measures for opportunity for improvement: Prenatal and Post-partum Care (PPC), and HbA1c Poor Control (HBD).

As a provider there are many opportunities to impact HEDIS® measures. This includes scheduling follow-up appointments, coordinating care, using correct diagnosis and procedure codes, documenting medical and surgical history in the medical record, including dates and submitting claims and encounter data in a timely manner.

Click on the links below to see Provider Tips on how you can help improve the ACO Quality Measures.

HEDIS® Measures

Provider Tips

Prenatal and Post-Partum Care (PPC)

Click here

Asthma Medication Ratio (AMR)

Click here

HbA1c Control for Patients with Diabetes (HBD)

Click here

Controlling High Blood Pressure (CBP)

Click here


Cultural sensitivity provider survey coming soon

As part of Mass General Brigham Health Plan (MGBHP)’s Health Equity Program, it is important to ensure that our members continue receiving the best culturally competent care possible. As one of this year’s initiatives to achieve this goal, MGBHP will conduct a cultural sensitivity provider survey to help us determine what type of cultural sensitivity training our providers have access to or need, what language services are available to members throughout the practice, and what linguistic resources our providers need. Watch for additional information and the survey link in the coming weeks.

Complete Access Exclusive Provider Organization (EPO)

We are constantly expanding our plan offerings to meet the healthcare needs of our customers and your patients. To support this goal, Mass General Brigham Health Plan introduced our Complete Access Exclusive Provider Organization (EPO) plan in 2024. For additional information and FAQs, please visit Complete Access EPO for providers


Help us keep directory information up to date

The Centers for Medicare & Medicaid Services and other regulatory bodies, as well as the federal No Surprises Act of 2021, require health plans to maintain and update data in provider directories. We rely on providers to review their data and notify us of changes as they happen, this ensures members have access to accurate information.

Provider demographic information in our Provider Directory must reflect accurate data at all times and should mirror the information members may receive directly from the practice or via patient appointment call centers.

On at least a quarterly basis, providers should review and verify the accuracy of their demographic data displayed in our Provider Directory. To report any changes to demographic data or to your address, panel status (open or closed) for each individual provider, institutional affiliations, phone number, or other practice data requests should be reported via the Mass General Brigham Health Plan Provider Portal provider.massgeneralbrighamhealthplan.org or by submitting a Provider Change via the Provider-Enrollment-Form to Mass General Brigham Health Plans Provider Enrollment Team by email at HealthPlanPEC@mgb.org.

Consistent with provisions related to the federal No Surprises Act of 2021, failure to review and update demographic information at least quarterly may result in suppression from Mass General Brigham Health Plan Provider Directory until the information is validated. In addition, if Mass General Brigham Health Plan identifies potentially inaccurate provider information in the directory, we may outreach to your practice to validate or obtain accurate information. If we are unable to obtain a timely response, the provider’s applicable location may be subject to suppression in the directory until up-to-date information is received.

In addition, please keep the following in mind:

  • Practice location — As new providers join your practice, it is important that only practice locations where the provider regularly administers direct patient care are submitted for inclusion in the Mass General Brigham Health Plan provider directory. Locations in which a provider may occasionally render indirect care — such as interpretation of tests or inpatient-only care — should be specified to ensure the location information is included in the provider’s demographic profile, but not in the provider directory.
  • Timely notice — As a reminder, notification of address, acceptance of new patients, provider terminations, and other demographic information changes should be submitted at least 30 days in advance.

For questions, contact our Provider Service Center at 855-444-4647 or provider.massgeneralbrighamhealthplan.org

Provider portal - Confirm patient eligibility, submit authorizations, and more

Our easy-to-use provider portal puts key information at your fingertips. On the portal, you and others in your practice can:

  • Verify patient eligibility
  • Submit or check authorizations and referrals
  • See your EOPs instantly
  • Access patient utilization stats and information
  • Change a member PCP
  • Manage the providers in your practice
  • And more

How to get started:

1. Register for the portal

2.  Watch our overview video to get accustomed to the portal 

3. Refer to the training deck for guidance on how to navigate the platform and complete common tasks


Tips for submitting a PCP change in the provider portal

When submitting a PCP change through the provider portal, make sure to follow these tips to prevent any potential errors:

    • Verify member’s eligibility prior to submitting a PCP change.
      Member’s eligibility can change at any given time and member may not be active with the plan on requested date of PCP change
  • The provider the member is being assigned to must have an open panel.
    • The provider the member is being assigned to must accept the member's plan type.
    • PCP assignments can be backdated for up to 60 days. 
      MGB ACO – New PCP must be within the same primary care site.
  • Future PCP assignments are limited to 60 days from today's date.
    • Please do not submit duplicate requests and allow up to 7 business days for the PCP change to process.


Step therapy exception request reminders

Massachusetts step therapy law contains broad reforms to step therapy protocols for Medicaid and commercial carriers, including new step therapy exception criteria. The standard prior authorization forms have been updated to include step therapy exception request questions.

There are a number of ways to submit a step therapy exception request, including as part of the electronic prior authorization form or by phone or fax. See below for further instructions.

Here's what providers need to know:

You can request a step therapy exception if you have evidence to believe the lower step treatments are not clinically appropriate, based on one or more of the following criteria:

You can request a step therapy exception if you have evidence to believe the lower step treatments are not clinically appropriate, based on one or more of the following criteria:

  1.    Member has previous history of one or more of the following:
  • Failure on the lower step therapy
  • Failure on another therapy in the same pharmacologic class or with the same mechanism of action as the lower step therapy
  • Stability on a prescription of the higher step treatment
  1.    The lower step therapy is not clinically appropriate because it is:
  • Contraindicated
  • Likely to cause an adverse reaction
  • Likely to cause physical/mental harm
  • Is expected to be ineffective based on known characteristics
  • Please provide clinical notes (e.g., name and strength of failed alternative and description of failure) references from peer reviewed journals, etc. during submission of step therapy exception requests and/or appeals.
  • Our updated step therapy exception criteria can be found here: CommercialMassHealth. Please ensure all required documentation is submitted.
  • Step therapy exception requests and appeals will be reviewed and granted or denied within 3 business days following the receipt of all necessary information.
  • If additional delay would result in significant risk to the health or well-being of the patient, urgent requests can be submitted for review within 24 hours following the receipt of all necessary information.
  • Medical necessity criteria are still required where applicable.
  • Please continue to ensure timely submission of prior authorization requests for both pharmaceutical and infusion medications. Prior authorizations for pharmacy should be submitted to Optum Rx (contact information below)

Medical and Specialty Medications All Plans:

Phone: 877-519-1908

Fax: 855-540-3693

Non-Specialty Medications All Plans

Phone: 800-711-4555

Fax: 844-403-1029


  • For infused medications, please submit prior authorizations via our provider portal.


Annual Mental Health Wellness Exams


Per MA DOI Bulletin 2024-02, we will cover an annual Mental Health Wellness Exam when billed under the medical benefit effective 4/1/2024 as follows: 
Diagnosis Code: Z13.30, Encounter for screening examination for mental health and behavioral disorders, unspecified
Service Code: 90791, Psychiatric diagnostic evaluation
Modifier: 33, Preventive Services: When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.
Frequency Limit: Annual
Services are provided at no member cost sharing except if the member is enrolled in an HSA qualified health plan (plan name includes the word ‘HSA’).
Mass General Brigham Health Plan’s Behavioral Health partner, Optum, will update our behavioral health providers via Provider Express. 


Optum Rx is our new pharmacy benefit manager

As previously announced, Optum Rx is Mass General Brigham Health Plan's new pharmacy benefit manager (PBM) effective January 1, 2024. As health care changes at a rapid pace, Mass General Brigham Health Plan continues to innovate and build on our total cost of care model. To create lasting value for our clients and members we serve now and, in the future, we changed our pharmacy vendor to Optum Rx. Making pharmacy care more affordable, accessible, supportive, and personal for our members is a shared goal with Optum Rx.

For frequently asked questions (FAQs) about Optum Rx and Specialty Fusions, please visit our dedicated provider resource page.




Temporary waiver of authorization for post-acute facilities

Mass General Brigham Health Plan is waiving prior authorization requests from January 9, 2024 until April 1, 2024 for patient transfers from acute care hospitals to sub-acute care facilities and rehabilitation facilities. This applies to initial admission to the sub-acute and/or rehabilitation. This is in support of the recent directive from the Massachusetts Executive Office of Health and Human Services (EOHHS).

Notice of Admission (NOA)

Notifications should be submitted by the respective Skilled Nursing and Acute Rehabilitation facilities within 24 hours of admission and updates provided a minimum of every 5 days to support discharge planning. 

Concurrent review and retrospective review will proceed (if notification occurred) to determine appropriateness of level of care.

Included in this waiver

  • Medicaid, Commercial and Medicare lines of business
  • INN providers
  • OON providers within Massachusetts

Excluded from this waiver

  • Long Term/custodial care
  • Out of network providers outside of Massachusetts

Commercial rate adjustment for telehealth services provided by non-PCP providers beginning January 1, 2024 

At the beginning of the COVID-19 pandemic, we implemented a temporary change to reimburse telehealth services on parity with in-person visits, in alignment with public health emergency recommendations and regulatory guidance.
On January 1, 2024, we returned to the pre-pandemic practice of a rate differential for services rendered through telehealth versus in-person. Services delivered via telehealth will pay at 85% of in-person rates, with exceptions for primary care and behavioral health. Primary Care services will continue to be reimbursed at 100% of in-person rates. Our behavioral health network is managed by Optum Behavioral Health. Optum BH applies rate parity for services delivered via telehealth. The MA DPH establishes rates for Early Intervention and Early Intensive Behavioral Intervention.
As we return to pre-pandemic operations and policies, we make these changes in accordance with MA 211 CMR 52.00, which implements MA Chapter 260 of the Acts of 2020 and related guidance. We will continue to communicate with you as more information becomes available.


Response to ED Boarding Crisis

Mass General Brigham Health Plan complies 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 applies to:

  • Commercial members, for dates of service 11/01/2022 and forward per MA DOI Bulletin 2022-08.

  • Medicaid members, for dates of service 01/03/2023 through 09/30/2023, per Mass Health guidance including MCE Bulletin 93 published November 2022.
  • Medicaid members, for dates of service 10/01/2023 and forward, per the MA Inpatient Acute General RFA effective 10/01/2023.

Mass General Brigham Health Plan complies with regulatory guidance to ensure Hospitals are reimbursed for behavioral health crisis evaluations and stabilization services, crisis management, recovery support navigators and the initiation of medication treatment for Opioid Use Disorders in the ED per the MA Inpatient Acute General RFA effective 10/01/2023.  

Provider payment guidelines | Mass General Brigham Health Plan


Hospital inpatient utilization report

The latest quarterly hospital inpatient utilization report is now available. To review this report, click on the Reports tab in the Provider Portal and select Clinical Reports. If you do not have access to the Provider Portal, you may register here.



ACO Bite-sized Bits

Behavioral Health Resources for PCPs

Explore our dedicated Behavioral Health Resources for PCPs page for convenient access to screening tools and valuable behavioral health resources. Additionally, Optum Health Education is offering a fantastic opportunity to earn 3 CME/NCPD credits through their engaging Behavioral Health Identification, Treatment, and Referral in Primary Care - A 3-Part On-demand Learning Series. Register for free and discover more training options available at Optum Health Education.

1099-MISC Provider Tax Forms

Eligibility: Only providers who were paid more than $600.00 in the previous tax year. 
Issued/mailed by: Echo, our delegated provider payment vendor.
Tax forms have been mailed out to the address we have on file

If you need a copy: Providers can access these forms via the Echo portal as they do their Explanation of Payment (EOP) copies. These forms can be viewed and/or download at: www.providerpayments.com. Providers with additional questions must contact our vendor Echo directly.


Medical policy updates

Eleven (11) 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.

For more information or to download our medical policies, go to https://www.massgeneralbrighamhealthplan.org/providers/medical-policies and select the policy under the medical policy listings.

Medical Policies

Policy Title


Products Affected

Effective Date

Radiofrequency Ablation to Treat Uterine Fibroids


April 2024: Ad-Hoc Review
  • Updated to allow exceptions to exclusion #1. 
All products


Outpatient Chest Physical Therapy April 2024: Annual Review- 
  • Coverage expanded to increase the number of allowable visits of acute exacerbations.
  • Coverage expanded to allow chronic therapy in members with recent hospitalizations, failure of airway clearance devices and no family member of caretaker available to provide therapy at the required frequency. 

All products



April 2024: Annual Review. 
  • Medicaid variation added.
  • Neutralizing antibody to AAV5 threshold changed to 1:700.
  • Minor changes to documentation requirements and to criteria 1.L. 

All products



April 2024: Annual Review.
  • Code added to code list.
  • Medicaid variation added. Minor edits. 

All products



April 2024: Annual Review.
  • Medicaid variation added.
  • Codes added to code list. 

All products



April 2024: New Policy.

All products



April 2024: New Policy. 

 All products



April 2024: New Policy.

 All products



April 2024: New Policy.

 All products


Mobile Cardiac Outpatient Telemetry

April 2024: Retiring Policy.

 All products


Bronchial Thermoplasty

April 2024: Retiring Policy.

All products



Drug code and code updates

View code updates for April 2024 here

New codes summary

View the April new codes summary here

Formulary updates

View the formulary updates here.