August 2024 - MassHealth encounter data deadline approaching, Steward Health Care update

Can preventive exercise reduce the risk of a sports injury?

Noncontact anterior cruciate ligament (ACL) injuries are 4-8 times more likely to occur in women than men due to sex-based differences in lower-extremity anatomy, neuromuscular control, and landing mechanics. Fortunately, the risk of ACL injuries can be significantly decreased with implementation and compliance with a preventive training program.

Miho J. Tanaka, MD, PhD, is the director of the Mass General Brigham Women’s Sports Medicine Program. An orthopedic surgeon and researcher, she’s known for her research on kneecap disorders and gender-based differences in sports injuries. Continue reading to learn about Dr. Tanaka’s journey into women’s sports medicine and how her work impacts female athletes. Read the full article.

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 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:

• Reimbursement for out-of-network urgent care centers
• Reminder: Tufts Medicine no longer part of ACO network effective July 1
• Change Healthcare claims submissions issues
• Upcoming webinar: Behavioral Health Supports for Primary Care Providers
• Provider resource: Authorization tip sheet
• MassHealth RY23 Encounter Data Deadline is August 31
• Important information regarding Steward Health Care
• Mass General Brigham Health Plan’s fee schedules to be updated on October 1
• Reminder: Medicare Advantage billing with Code 80050
• Electronic Visit Verification (EVV) resources 
• Provider resource: Preventive Services Grid
• Improving call wait times
• Help us keep directory information up to date
• Tips for submitting a PCP change in the provider portal
• Genetic testing requests with eviCore Healthcare
• Medical policy updates
• Medicare provider notification
• Drug code and code updates
• New code updates for ACO and commercial plans
• New code updates for Medicare Advantage plans
• Formulary updates

Reimbursement for out-of-network urgent care centers

Beginning on July 3, 2024, and ending on October 1, 2024, Mass General Brigham Health Plan is reimbursing out-of-network urgent care centers in Massachusetts as requested below. This is in support of the recent directive from the Massachusetts Executive Office of Health and Human Services (EOHHS) and Assistant Secretary for MassHealth. Mass General Brigham Health Plan will reimburse urgent care centers in eastern Massachusetts* as follows:

• For Commercial members receiving services provided in urgent care centers with providers with whom Mass General Brigham Health Plan has a contract, but who do not participate in a member’s health plan, Mass General Brigham Health Plan will provide reimbursement for medically necessary urgent care services at the contracted rate for delivered services. Out-of-network providers are not allowed to balance bill members during this time.
  
  
• For Commercial members receiving services provided in urgent care centers with providers with whom Mass General Brigham Health Plan does not have any contract, Mass General Brigham Health Plan will reimburse medically necessary urgent care services at a rate equal to 135% percent of the rate paid by Medicare for medically necessary urgent care services. Out-of-network providers are not allowed to balance bill members during this time. 
  
  
• The MassHealth Program will reimburse at 100% of Medicaid.

Non-contracted providers in Massachusetts should submit claims directly to Mass General Brigham Health Plan (Payer ID: 04293). Please review our payment options and claims resource page before submitting claims using one of the following methods:

• Call Provider Service at 855-444-4647
• Mail paper claims to PO Box #323, Glen Burnie, MD 21060
• Submit a claim through the Provider Portal at MassGeneralBrighamHealthPlan.org
• Submit an electronic EDI claim to Payer ID 04293

For questions about reimbursement, please email HealthPlanProvRelations@mgb.org or visit the Provider Portal at Provider.MassGeneralBrighamHealthPlan.org.

*Commercial is limited to these counties: Essex, Middlesex, Suffolk, Norfolk, Bristol, Plymouth, Barnstable, Dukes, and Nantucket

Change Healthcare claims submission issues

Due to the cybersecurity incident involving Change Healthcare, providers faced challenges when submitting claims through the ECHO Clearing House, as well as when submitting corrected claims and appeals. As a result, Mass General Brigham Health Plan will be waive timely filing for any claims submission or request for claims appeals for claims with dates of service 11/21/23-5/31/24. We ask that you submit original or corrected claims no later than August 20, 2024, to have timely filing waived/considered.

Providers need to complete the timely filing waiver form to attest the claims were impacted by the Change Healthcare incident and submit the completed form to healthplanprovrelations@mgb.org. Please ensure to include the Timely filing waiver form in any mailed in correspondence such as Request for Claims Review, COB, Appeals. 

Upcoming webinar: Behavioral Health Supports for Primary Care Providers

Mark your calendars! Don't miss out on our upcoming live webinar on Behavioral Health Supports for Primary Care Providers, happening on
Monday, September 9. The webinar is scheduled from 12:00 p.m. to 1:00 p.m. and will be recorded for convenient on-demand viewing. Keep an eye out for an email invitation with all the details prior to the event. For any questions, feel free to contact Keri Sperry at ksperry@mgb.org.

Provider resource: Authorization tip sheet

Wondering about services that need prior authorization, where to submit requests, or how to track authorization status? Check out our new authorization tip sheet with helpful guidance and resources for you and your practice. View the authorization tip sheet.

MassHealth RY2023 encounter data submission deadline is August 31 

As previously announced, MassHealth has extended its RY23 encounter data submission deadline to August 31. 

Each year, Mass General Brigham Health Plan is required to submit encounter data to the Commonwealth of Massachusetts for all ACO members. The information submitted includes final encounter data from claims with service dates from the previous year.

In order to meet this requirement, all claims for dates of service (DOS) between April 1, 2023, and December 31, 2023, should be submitted by August 31, 2024. Submitting claims by this deadline will ensure that the information is provided to the State within the necessary timeframe. Please be aware that timely filing limits apply.

For guidance on submitting claims, please visit our claims resource page.

Reminder: Tufts Medicine no longer part of ACO network effective July 1

As previously announced, Tufts Medicine affiliates and specialists are no longer part of the Mass General Brigham ACO provider network effective July 1. There is no impact to primary care, and ACO members can continue to see their current primary care providers. In addition, ACO members can continue to access high-quality specialty care with in-network providers and receive urgent or emergency care at Tufts Medicine facilities. We are working with Tufts Medicine and our ACO providers to ensure that members have access to the care and support they need.

FAQS

How will ACO members be supported through this transition?

We are working with Tufts Medicine and our ACO providers to ensure that members have access to the care and support they need, which includes outreach to high-risk members.

Where should ACO members be referred to for specialty care moving forward?

To find an in-network provider after July 1, we are encouraging members to visit our provider directory at massgeneralbrighamhealthplan.org/find-provider. If you have any additional questions, please contact the MGBHP Provider Service team at 855-444-4647 or HealthPlanProvidersService@mgb.org.

I have an ACO member who is currently receiving care at a Tufts Medicine facility/from a Tufts Medicine specialty provider. Do they need to switch?

ACO members can continue to access high-quality specialty care through a variety of in-network providers. After July 1, 2024, members will need an out-of-network authorization to access specialty care through Tufts Medicine providers and facilities.

Important information regarding Steward Health Care

We are closely monitoring the situation with Steward Health Care, including its announcement about closing Carney Hospital and Nashoba Valley Medical Center. As we continue to track new developments, we have prepared contingency plans to ensure our members have access to the care they need.

We encourage members with concerns about the planned closures to contact their provider or the number on their health plan ID card. Our customer service team can help to answer questions and support timely access to care.

For ongoing updates about Steward Health Care facilities in Massachusetts, the state has set up a dedicated website at mass.gov/stewardresources and hotline at 617-468-2189 (local) or 833-305-2070 (toll-free).

Mass General Brigham Health Plan’s fee schedules to be updated on October 1

Mass General Brigham Health Plan reviews its drug fee schedules quarterly to ensure that they are current, comprehensive, and consistent with industry standards, to the extent supported by its systems. In most cases, changes involve adding fees for new or existing codes, to supplement the fees already on the fee schedule. 

The next update will occur on October 1, 2024. Changes may involve both new and existing CPT and HCPCS codes and will include the planned quarterly update to physician administered drugs, immune globulin, vaccine and toxoid fees.

The Plan will also be updating any Medicare Advantage fee schedules, on October, 1, 2024, if CMS has published any updates.

Reminder: Medicare Advantage billing with Code 80050

Just a friendly reminder, the code 80050 is a bundled lab code and needs to be unbundled to request specific services. The laboratory panel represented by CPT code 80050 is not covered under Medicare. Bill another HCPCS laboratory panel code if appropriate or bill the individual component tests. See the Medicare Claims Processing Manual, Pub. 100-04, chapter 16, section 90.2. If the laboratory repeats one of the component tests as a medically reasonable and necessary service on the same date of service, the CPT code corresponding to the repeat laboratory test may be reported with modifier 91 appended. 

Electronic Visit Verification (EVV) Resources 

The Massachusetts Executive Office of Health and Human Services (MA-EOHHS) and Sandata, the state-sponsored Electronic Visit Verification (EVV) provider, hosted a town hall on June 25, 2024. We are excited to provide you with valuable resources to continue your education around the EVV requirements and the state-sponsored EVV provider.

Whether you attended or couldn’t make the first town hall, these resources are available at Sandata On-Demand and offer a wealth of information to help you stay informed and engaged:

• Town Hall #1 Recording
• Town Hall #1 Presentation deck
• Town Hall #1 Transcript

Check out Sandata On-Demand for a Question & Answer document that will help you navigate Sandata functionality.

We will share other resources as we move closer to go-live for the EVV program. A registration email will be sent out in the coming weeks for the second MA-EOHHS/Sandata Town Hall, so be on the lookout. Topics covered in that Town Hall will include training, alternate EVV specifications, provider and vendor registration, and more.

Considering using an Alternate EVV (Alt EVV) vendor?

Please view the Alt EVV Technical Specification on Sandata On-Demand. These specifications will be discussed in greater detail during the next Town Hall.

Contacts and resources

For technical questions in using the Sandata EVV system, please Submit a Request via Sandata On-Demand. For all other EVV-related questions, please reach out to EVVfeedback@Mass.gov.

Provider resource: Preventive Services Grid

As summer continues, back-to-school physicals and other preventive service visits will be on the rise. The Preventative Services Grid is a valuable tool for providers to accurately bill preventative services. It is not uncommon for offices to inadvertently use inaccurate codes or DX, resulting in member cost sharing. Bookmark and view the Preventive Services Grid.

MassHealth members eligible for free doula services

Did you know MassHealth members can receive free doula service during pregnancy, birth, and after? Below are the doula services covered by MassHealth:

• Support during labor and delivery or birth.
• Up to 8 total hours of visits during pregnancy and during the 12 months after the end of pregnancy. Members work with their doula to decide when to have their visits.
• If a member needs more than 8 total hours of visits during this time, they can speak with their doula about MassHealth's prior authorization process, which determines if they can get coverage for more visits.

View the MassHealth doula services flyer here. Members can learn more about the program and find a MassHealth doula provider at mass.gov/masshealthdoulas. Members can also contact the MassHealth Customer Service Center for more information at (800) 841-2900, TDD/TTY 711.

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 p..m-12:45 p.m. and Wednesdays from 9:30 a.m.-10:30 a.m.). You can also contact us through our provider email address at HealthPlanProvidersService@mgb.org.

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

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.

Genetic testing requests with eviCore Healthcare

Mass General Brigham Health Plan partners with eviCore Healthcare for genetic testing requests. Beginning 9/1/2024, all first-level appeal requests for denied genetic testing will also be handled by eviCore Healthcare, streamlining the process and maintaining expertise in reviews. Moving forward, all first-level appeals can be submitted directly through the eviCore Healthcare portal.

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.

Drug code and code updates

View code updates for August 2024 here. 

New code updates for ACO and commercial plans

View the code updates for July 2024 here.

New code updates for Medicare Advantage plans

View the code updates for July 2024 here.

Formulary updates

View the formulary updates here.