New Member ID Cards and Numbers, Optum Rx Training in December, Vaccine Alerts for RSV and COVID-19

Featured story: How volunteering affects your health

Mass General Brigham is committed to working with community residents and organizations to make measurable, sustainable improvements in the health status of underserved populations. As part of this commitment, we want to acknowledge International Volunteer Day, which falls on December 5, recognized by the United Nations as a way to “highlight the power of our collective humanity to drive positive change through volunteerism.” This recognition comes at the start of National Giving Month, an effort highlighting the work of nonprofits and the generosity and volunteerism that fuels them. 

There’s little doubt that volunteering makes a significant impact on communities and individuals, and here’s one more reason to consider finding these opportunities: It can be a major health booster. Here are some ways volunteering can affect your physical and mental well-being. Read the full article.

In this issue:

• New member ID cards and numbers for January 1, 2024
• Register for Optum Rx training on December 12 or 14
• Referral requirements for MGB ACO
• Rate adjustment for telehealth services provided by non-PCP providers beginning January 1, 2024
• Complete Access Exclusive Provider Organization (EPO)
• MassHealth reimbursement for behavioral health crisis management 
• Appeal resolutions update from 30 to 60 calendar days
• Vaccine alert: Correct dosage and administration of Moderna COVID-19 vaccine for individuals 6 months through 11 years of age 
• Vaccine alert: Use the correct RSV immunization on infants
• DME overage requests

• 2024 ConnectorCare changes

• Provider resource center - popular forms and tools for your practice
• Prior authorization requests
• Win a $100 gift card - Confirm your directory information and next available appointments
• Credentialing information for Urgent Care Center applications 
• Medical policy updates
• Medicare provider notification
• Drug code and code updates
• Formulary updates

New member ID cards and numbers for January 1, 2024

Mass General Brigham Health Plan is updating member ID numbers and cards for all members effective January 1, 2024. Members will receive a letter with their new ID card closer to January 1, 2024. With this update, all individuals across membership populations will have the same prefix, R22, in their new ID numbers. There will be a transition period of at least 90 days where both the old and new ID numbers can be used post January 1, 2024.

Frequently asked questions

• Who is receiving new member ID numbers?
  All current and new members will be receiving a new member ID number and member ID card. Please note: New members or members with updated eligibility segments will be assigned an R22 member ID number prior to January 1, 2024. Claims should be submitted with the appropriate ID number displaying in the Provider Portal.

• How do I verify a member’s ID number?
  Please verify a member’s ID number by visiting the Provider Portal.

• When should members begin using their new member ID numbers?
  Members should begin using their new member ID numbers beginning on January 1, 2024. 
  Please note: if a member receives their R22 ID number before January 1, 2024 due to a change in eligibility, they should begin using that new ID number immediately.

• Which member ID number should I use for services delivered before January 1, 2024?
  Please use the current ID number found in the Provider Portal. There will be a transition period of at least 90 days where both the old and new ID numbers can be used post January 1, 2024.

• Will member ID numbers be updated for existing prior authorizations?
  Yes, member ID numbers will automatically update for existing prior authorizations.

• If all member IDs start with the same prefix, R22, how do I distinguish the type of membership a patient has?
  Please reference our authorization guidelines and/or code checker in the Provider Portal to determine membership type.

• Are benefits changing for members?
  No, member benefits are not changing, unless the group and/or member has renewed into a new plan during the same time.

• Will members need to sign up for the Member Portal again?
  No, access to the Member Portal will not be impacted.

We ask that you please confirm the ID numbers of all Mass General Brigham Health Plan members when delivering care to ensure that services are properly billed. If members have questions, please direct them to our Customer Service team at 866-414-5533 or  HealthPlanCustomerService-Members@mgb.org for additional support.

Register for Optum Rx training on December 12 or 14

As previously announced, Mass General Brigham Health Plan will work with Optum Rx as our new pharmacy benefit manager (PBM) beginning 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 are changing 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.

Provider trainings will be offered for Specialty Fusion, a system that integrates medical and pharmacy benefits into a single platform, so you can streamline your process while gaining full visibility to specialty trends. Please register for one of the two sessions below. Both sessions will cover the same content:

• Tuesday, December 12, 2023 - 10:00 AM EST to 11:00 AM EST Register here
• Thursday, December 14, 2023 - 4:00 PM EST to 5:00 PM EST Register here

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

Referral requirements for Mass General Brigham ACO 

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 will return 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.  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.
 
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.

MassHealth reimbursement for behavioral health crisis management 

Mass General Brigham Health Plan will comply with MassHealth guidance to ensure hospitals are reimbursed for ongoing team-based behavioral health crisis management after the initial behavioral health crisis evaluation. Additionally, Mass General Brigham Health Plan will reimburse hospitals for Recovery Support Navigator services and the Initiation of Medication for the treatment of Opioid Use Disorders in the Emergency Department.

This will apply to:

• MassHealth members, for dates of service 10/01/2023 and forward, per EOHHS guidance.

For billing information applicable to Mass Health members for dates of service 01/01/23-09/30/23, please refer to our provider payment guideline:  CrisisInterventionEDBoarding.pdf (allwayshealthpartners.org)

Appeal resolutions update from 30 to 60 calendar days

To align with industry standards and meet the expectations of our provider community, Mass General Brigham Health Plan will be increasing the timeframe of appeal resolutions from 30 calendar days to 60 calendar days.

Vaccine alert - Correct dosage and administration of Moderna COVID-19 vaccine for individuals 6 months through 11 years of age 

The FDA has found that some healthcare providers may not recognize that the single dose vial of Moderna COVID-19 Vaccine (2023-2024 Formula) contains more than the necessary 0.25 mL of the vaccine for use in individuals 6 months through 11 years.  

Please follow the below guidance when administrating the vaccine to ensure the correct dosage is used for individuals six months through eleven years: 

• Correct dose is 0.25 mL/25 mcg 
• Ensure the correct volume of the vaccine (0.25 mL) is withdrawn from the vial and administered to the recipient 
• Discard vial and excess volume after extracting a single dose (there may be significant excess volume left in the vial) 
• Never combine partial doses from multiple vials to make one dose for a patient 

Please be assured that the FDA has not identified any safety risks associated with the administration of the higher dose in patients 6 months through 11 years. No serious adverse events have been reported related to a dosing error for the vaccine. 

For additional information, we encourage you to refer to the FDA Announcement, the updated Moderna COVID-19 Vaccine (2023-2024 Formula) Healthcare Provider Fact Sheet (fda.gov), and Moderna COVID-19 Vaccine At A Glance: Updated 2023-2024 Formula (cdc.gov) 

Vaccine alert - Use the correct RSV immunization on infants

From the Massachusetts Department of Public Health- MDPH has been alerted by CDC of multiple reports of vaccine providers who have inadvertently administered RSV vaccines (Arexvy or Abrysvo) to infants, rather than giving them the RSV monoclonal antibody product recommended for infants. The recommended immunizing product (RSV monoclonal antibody) for infants is nirsevimab (trade name: Beyfortus, commercialized by Sanofi and manufactured by AstraZeneca). 

As a reminder, 

• RSV vaccines (Arexvy or Abrysvo) are not approved or recommended for use in infants and young children.
• These RSV vaccines (Arexvy or Abrysvo) have not been studied in infants and young children; therefore, vaccine safety and effectiveness for this population  unknown.
• Abrysvo is recommended for pregnant persons at 32 weeks through 36 weeks gestation.

RSV Immunizations

• RSV (Respiratory Syncytial Virus) Immunizations | CDC
• Healthcare Providers: RSV Immunization for Children 19 Months and Younger | CDC
• Frequently Asked Questions About RSV Immunization with Monoclonal Antibody for Children 19 Months and Younger | CDC 
• RSV Vaccination: What Parents Should Know | CDC
• ACIP and AAP Recommendations for Nirsevimab | Red Book Online | American Academy of Pediatrics
• Health Alert Network: Limited Availability of Nirsevimab in the United States – Interim CDC Recommendations to Protect Infants from RSV During the 2023-2024 Respiratory Virus Season

Vaccine Administration

• Vaccine Administration Protocols | CDC
• Vaccine Administration: Preventing Vaccine Administration Errors (cdc.gov)
  
  

DME overage requests

For any DME overage requests, a prior authorization needs to be submitted with the following information in the “Remarks” Section: 

• “The following is for an overage request for (appropriate codes and quantity) and requires Medical Necessity Review (with reason for request).” 

Supporting clinical documentation needs to be submitted at the time of request to complete the review process.

Billing DME overage claims:
In addition to securing the appropriate authorization, claims must be submitted with the appropriate date range to match the units being billed. If you have received a denial due to units and have an authorization on file, you will need to resubmit your claims with the appropriate date ranges.

2024 ConnectorCare changes

New in 2024, Mass General Brigham Health Plan will be offering our full network product, Complete HMO in ConnectorCare to meet the new Massachusetts Health Connector’s requirement. The Complete HMO will be sold alongside our current high-performance network product, Select HMO. Click here to see a sample of the Complete HMO ConnectorCare member ID card.

Provider resource center - popular forms and tools for your practice

We’ve made it easy for you to do business with Mass General Brigham Health Plan by organizing popular forms and resources on one resource page. Here's a sample of what's available:

Clinical Resources:

• Medical Policies - Medical policies provide you with the coverage criteria for specified conditions. You can find more information on the utilization management (UM) decision making process and how to obtain UM criteria in the Provider Manual.
• Clinical Contact Information - Clinical staff is available at 855-444-4647 Monday-Friday (8:30 AM - 5:00 PM). After hour coverage is available after 5 PM on weekdays and on the weekends.
• Case Management Programs - You can get more information on specific programs and how you can refer a member into one of our case management programs. Providers can refer by emailing: HealthPlanCareManagement@mgb.org 
• Tobacco Cessation - For members who are trying to quit tobacco, we offer a tobacco cessation program run by our Certified Tobacco Treatment Specialists. Providers can refer by email: HealthPlanQuitSmoking@mgb.org 
• Health Coaching - Health coaching is available for members trying to improve eating habits, increase their physical activity, manage weight and decrease stress. Our health coaches have all completed the rigorous Wellcoaches® school of coaching training program. Providers can refer by emailing: HealthPlanHealthandWellness@mgb.org 

Provider Manual

The Provider Manual includes important information on how you can support your patient. Topics in the Provider Manual include:

• Quality Improvement Program
• Utilization Management Decision-Making - This includes information regarding our decision-making process and procedures. We do not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service, nor do we provide financial incentives to UM decision-makers to encourage decisions that result in under-utilization.
• Credentialing and Re-credentialing Processes
• Member Rights & Responsibilities
• Practitioner Rights & Responsibilities
• Interpreter Services

Pharmacy Benefit Program

Our website gives you the most up-to-date information about our Pharmacy programs, covered medications and the current medical necessity criteria. Pharmacy programs include:

• Excluded Medication - A medication which is considered to be excluded from the pharmacy benefit.
• Pharmacy & Therapeutics Committee - This Committee is chaired by the Medical Director responsible for pharmacy and is composed of practicing pharmacists and practicing providers with varying specialties, including behavioral health, internal medicine and pediatrics. It meets regularly throughout the year, no less frequently than quarterly.
• Prior Authorization - A pharmacy program which limits access to a medication by establishing criteria for appropriate use of a medication. These criteria must be met and documentation sent to us before the medication will be covered. Prior authorization is also required for exception to our mandatory generic medication pharmacy benefit.
• Quantity Limit - A pharmacy program that limits the number of units per time period for a specific medication based on recommended doses.
• Step Therapy - A pharmacy program which allows patients who meet criteria to have coverage for their prescription adjudicate without review based on available medication history.
• Mandatory Generic - A pharmacy program which requires a trial of an FDA approved generic substitution for a brand name medication, if it is available.
• Tier Placement - A pharmacy program that places medications in one of six co-payment tiers for benefit plans with a six-tier pharmacy benefit.
• Therapeutic Interchange/Substitution - A pharmacy program that involves the dispensing of a chemically different drug, considered therapeutically equivalent, i.e., will achieve the same outcome, in place of a drug originally prescribed by a physician. The drugs are not generically equivalent. Therapeutic substitutions are done in accordance with procedures and protocols set up and approved by physicians in advance. Therefore, the pharmacist would not have to seek the prescribing physician's approval for each interchange.

Visit the Provider resource center 

Provider portal and prior authorization requests update

Effective 11/1/23, Fax number are a mandatory field on the provider portal.  This upgrade is being put in place to help facilitate requests for additional information when needed.

Please ensure that all necessary clinical information is included at the time the prior authorization request is submitted.  This is to ensure timely processing of your requests.

Win a $100 gift card - Confirm your directory info and next available appointments

Please take a few minutes to complete both of the following brief forms by December 15 and you'll be automatically entered into our drawing to win a $100 gift card. 

1. Provider Directory Accuracy: Let us know if your information is accurate by completing this form.  
2. Future Appointment Access: Let us know about your next available appointments by completing this form.
   
   

Credentialing information for Urgent Care Center applications 

The following credentialing information is required when submitting an Application for Urgent Care Centers:

Urgent Care details below:

• CLIA
• W9
• Copies of State License(s) (If Applicable)
• Medicaid Certificate/Letter
• Medicare Certificates/Letter
  • • • Certificate of Accreditation
        -Accreditation of Association for Ambulatory Health Care (AAAHC)
        -Urgent Care Association (UCA)
        -The Joint Commission (TJC)
      • Copies of Malpractice/Liability Insurance Policy Face Sheets
      • Detailed List/Catalog of services provided
      • Federally Required Disclosure
      • If no accreditation, please include current site-visit documentation approved by the DPH
      • Mass Health PIDSL and Participation of Evidence (if ACO Provider)

Please note that Urgent Care Centers are recredentialed every two (2) years.

Medical policy updates

Seven 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.

2024 Medicare provider notification

View the Medicare Provider Notification here.

Drug code and code updates

View code updates for December 2023 here. 

Formulary and NCCN update

View the formulary updates here.