April 2025: Annual CAHPS survey; register for the spring regional provider meeting

Six tips to better accommodate patients with autism

Healthcare settings can be overwhelming for anyone, but that can be especially true for patients with autism. Between the bright lights, noisy offices, and unpredictable wait times, a routine checkup can quickly devolve into a distressing situation. However, with some simple, thoughtful accommodations, providers can create a more positive experience for those patients and a more accessible environment overall. 

Patients with autism can have difficulty navigating uncertainty. Help them feel more in control of the situation by using plain language and avoiding jargon, offering a visual explanation of what they can expect during their appointment, and providing them with written instructions for aftercare. Having something to look back on can make a world of difference. Read the full list.

Contact

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. 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: Provider.MGBHP.org 

In this issue:

• Ancillary professional providers can contact Provider Relations for assistance
• ACO Spotlight: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program updates
• Register now: Spring regional provider meeting on May 20
• Meet the Provider Relations team: Meghan Morrissey
• Update to prior authorization review for transfers from acute care to post-acute care facilities
• MassHealth prior authorization updates for APAD and APEC carve-out drug 
• Update to prior authorization requirement for observation stays 
• Annual CAHPS survey on its way to Medicare Advantage members
• Video: Submitting claims and claims reviews in the Provider Portal
• MassHealth RY24 encounter data deadline is July 31
• ACO Bite-sized Bit: MassHealth preferred GLP1 is Zepbound
• Multiple procedure reduction rule in progress, expected completion August 1, 2025
• Help us keep directory information up to date
• Medicare Advantage FQHC billing guidelines
• Medical policy updates
• Drug code and code updates
• Formulary updates
• Medicare pharmacy updates

Ancillary professional providers can contact Provider Relations for assistance

To assist with current call wait times, ancillary professional providers may email the Provider Relations team at HealthPlanProvRelations@mgb.org as an alternative communications method. 

ACO Spotlight: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program updates

As a reminder, MassHealth published updates to the Medical Schedule and Dental Schedule, and service codes for the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. These updates went into effect in November 2024.

Updates included but are not limited to:

1. Screening the child’s parent(s) or caregiver(s) for postpartum depression should now occur at every preventive pediatric visit from the one-month visit to the twelve-month visit, which is consistent with Chapter 186 of the Acts of 2024 (the new MA maternal health law).
   
   
2. Updates to the Medical Schedule and recommended screening tools to further align with the Bright Futures Guidelines and Periodicity Schedule and the Massachusetts Health Quality Partners Pediatric Preventive Care Guidelines.
   
   
3. The MassHealth Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program Medical Schedule Table, a new visual that shows all EPSDT Medical requirements by age in one place.
   
   
4. Updates to the Dental Schedule to be consistent with the Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents from the American Academy of Pediatric Dentistry

Review the full MassHealth announcement here, including the Dental Schedule on page 13. The Medical Schedule can be found here.

Register now: Spring regional provider meeting on May 20

We're excited to invite you to our spring regional provider meeting on Tuesday, May 20, from 9 a.m. to 12 p.m. at our Assembly Row headquarters in Somerville, MA. Please RSVP here by May 9.

Meet the Provider Relations team: Meghan Morrissey

We're thrilled to introduce you to a fantastic member of our Provider Relations team! This month, meet Meghan Morrissey, our Senior Provider Network Account Executive. Meghan has been a valued part of Provider Relations for over 12 years.

Some of the providers in Meghan's network territory include: Atrius, Beth Israel Lahey Health, Reliant Medical Group, Tenet Healthcare, Tufts Medicine Integrated Network, South Shore Health, and UMass Memorial Health.  

If you're in Meghan's network area and would like to get in touch with her, please email mmorrissey4@mgb.org. 

Update to prior authorization review for transfers from acute care to post-acute care facilities

In accordance with Chapter 197 of the Acts of 2024 (recent state legislation), we are making changes to our procedures, including our prior authorization review of transfers from acute care to post-acute care facilities (Skilled Nursing, Acute Rehab and/or Long-Term Acute Care). 

Authorization transfer requests to post-acute facilities made on business days, will be reviewed within 1 business day following receipt of all necessary information to establish medical necessity for the transfer. We are defining “business days” as the days the Health Plan is open.

For members transferring from acute inpatient to post-acute facilities on non-business days or holidays, we will approve the first 3 calendar days of the admission. We are defining “non-business” days as weekends and holidays.  

A prior authorization is still required for all post-acute transfers within 1 business day of the transfer, but if it is occurring on a non-business day, the facility will not have to wait to obtain approval from MGBHP before transferring. Please ensure that a prior authorization takes place for all days of the admission, to ensure claims.

For transfers made on non-business days, Concurrent/Continued Stay reviews will proceed on day 4, to determine appropriateness of level of care.  If a transfer is made on a non-business day, a retrospective review will not occur for any days already approved.

In addition, for transfers that take place on regular business days, the health plan will review the authorization request and make a medical necessity determination for admission to a post-acute care facility by the next business day following receipt of all medically necessary information to establish medical necessity. For regular business days, an approval from the health plan is required prior to transfer.

For any post-acute medical necessity denial, all appeals will be handled on an expedited basis.

This applies to lines of business as follows: 

• Applies to Medicaid and Commercial Lines of Business
• Applies to in network post-acute facilities ONLY (does not apply to out of network facilities) 
• Self-insured ASO accounts may have applied different guidelines 
• Does not apply to Medicare Advantage Line of Business 

MassHealth prior authorization updates for APAD and APEC carve-out drugs

MassHealth recently published Managed Care Entity Bulletin 125 related to changes in prior authorization for APAD and APEC carve-out drugs effective April 1, 2025.

These drugs will become a wrap service for MassHealth members. Providers are required to submit prior authorization requests to MassHealth for the drugs but requests for other services related to the care to the health plan. Similarly claims for drugs should be submitted to MassHealth and claims for other associated services should be submitted to Mass General Brigham Health Plan.

Update to prior authorization requirement for observation stays 

To support timely access to care and reduce administrative burden, Mass General Brigham Health Plan, is removing the prior authorization requirement for observation stays for our Medicaid and Commercial members.  Effective 5/1/25, observation stays up to 48 hours (two calendar days) will be covered without prior authorization. Providers should follow standard prior authorization procedures for length of stay’s greater than 48 hours and an inpatient admission is required.  Inpatient hospitalization requests require a separate authorization.

This change is designed to streamline the care process while ensuring proper claims processing.  Providers should continue to follow standard clinical documentation and billing practices.  Thank you for your continued partnership in delivering quality care to our members.

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.

Annual CAHPS survey on its way to Medicare Advantage members

It’s CAHPS season! The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is here! This nationally standardized tool measures patient experiences with healthcare providers and systems including health plans. During this time, patients and health plan members will be surveyed using a multi-modal approach to gather valuable feedback.

We need your partnership to ensure every patient and health plan member receives exceptional care—when they need it, where they need it, and how they need it. Below, we’ve outlined practical, proven tips to help you deliver compassionate care that aligns with key Medicare Star measures.

We’re here to help!

Mass General Brigham Health Plan is committed to supporting you during CAHPS season and beyond. If you have questions about the survey or need guidance on enhancing patient experiences, reach out to your Provider Relations Representative.

Thank you for your continual dedication and partnership in delivering outstanding care to our patients and health plan members!

Video: Submitting claims and claims reviews in the Provider Portal

We’re excited to announce you can submit claims and claims reviews in the Provider Portal. When submitting a claim or claim review, a transaction number confirming receipt of submission will be available and providers can track the status of a submission within the Provider Portal. Please note, a claim review form must be completed and attached to the online claim review submission. Please review the video walkthrough of the new features below or read the overview. If you need assistance with the Provider Portal, please contact HealthPlanprweb@mgb.org.

MassHealth RY24 encounter data deadline is July 31

MassHealth has communicated to all plans that 2024 claims must be adjudicated by July 31, 2025.  This means all providers must submit claims with a 2024 date of service no later than July 1, 2025, to meet this adjudication deadline.  If there are questions or concerns about 2024 claims, please contact Customer Service or your Provider Account Executive. We appreciate your collaboration on these efforts over the coming months.

ACO Bite-sized Bit: MassHealth preferred GLP1 is Zepbound

For Masshealth members, as of January 1, 2025, Wegovy and Saxenda will no longer be covered for the treatment of overweight or obesity in adults. The Masshealth preferred GLP1 for weight loss for adults is now Zepbound. Additionally new starts for GLP1 medications for weight loss will now require a trial and failure of phentermine with or without topiramate for 90 of the prior 120 days. 

Multiple procedure reduction rule in progress; expected completion August 1, 2025

Mass General Brigham Health Plan’s update to its multiple procedure reduction rule remains in progress and is expected to be completed by
August 1, 2025.

Multiple Procedure Reduction Rule: When multiple surgical procedures are performed in the same operative session, the procedure with the highest RVU will be reimbursed at 100% of the allowed amount and all subsequent, lower RVU-valued procedures, will be reduced per the Plan’s Modifiers Provider Payment Guidelines, unless otherwise specified in the provider’s contract.

Medicare Advantage FQHC billing guidelines

It has come to our attention that some Federally Qualified Health Centers (FQHCs) are not submitting bills for Medicare Advantage in compliance with CMS billing guidelines and Mass General Brigham Health Plan billing instructions. Kindly review the guides below and reach out to Provider Relations if you have any questions:

 Medicare Advantage FQHC/RHC billing guide

Provider payment guidelines: Community health centers   

Medical policy updates

Nineteen (19) medical policies were reviewed and passed by the Mass General Brigham Health Plan’s Medical Policy Committee. View a summary of the updates here. These policies are now posted to MGBHP.org.

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

Drug code and code updates

View code updates for April 2025 here. 

Formulary updates

View the formulary updates here.

Medicare pharmacy updates

View the Medicare pharmacy updates here.