Virtual primary care visits increase access and convenience for patients
Virtual care continues to grow in popularity for patients and providers. Almost 9 in 10 healthcare leaders are seeing the positive impact of virtual care in addressing staff shortages in their organization. Plus, 32% of healthcare leaders say virtual care enables them to expand specialist care to underserved communities.
Our members at Mass General Brigham Health Plan can access alternative options for primary care through virtual practices. These virtual practices allow members to get the same high-quality primary care they’d receive in an office delivered online. Virtual and hybrid practices—ones that offer virtual and in-person care—are great options for individuals looking to start a primary care relationship quickly or prefer to receive care online from the comfort and convenience of their own home. 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. 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:
- Introducing our Deputy Chief Medical Officer: Edward Yoon, MD, MBA
- Video: Submitting claims and claims reviews in the Provider Portal
- Rx Savings Solutions: Help your patients control their prescription drug costs
- Launch date change: Home health authorization update
- Non-MGB provider language services notification
- Multiple procedure reduction rule in progress, expected completion in February
- ACO Spotlight: February is National Children’s Dental Health Month
- Help us keep directory information up to date
- Annual code and rate updates
- Medicare Advantage FQHC billing guidelines
- Medical policy updates
- Medicare provider notification
- Drug code and code updates
- Formulary updates
Introducing our Deputy Chief Medical Officer: Edward Yoon, MD, MBA
We are pleased to share that Edward Yoon, MD, MBA has joined Mass General Brigham Health Plan as our Deputy Chief Medical Officer (CMO). In this role, Dr. Yoon leads our clinical programs to ensure an exceptional healthcare experience for our members. Dr. Yoon brings over two decades of leadership experience in managed care and provider organizations. Please join us in warmly welcoming Dr. Yoon to our organization.
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.
Launch date change: Home health authorization update
The December launch date for our home health authorization update has moved to Monday, April 7. We apologize for any confusion this has caused. As previously announced, the way you enter homecare authorizations through the Provider Portal will be updated. This will impact homecare authorization requests placed through the Provider Portal. Providers will have to submit a separate request for each discipline.
For example, skilled nursing, physical therapy, and occupational therapy, if requested at the same time for the same period, would require separate entries through the Provider Portal. The only exception will be Skilled Nursing and Medication Administrative Visits (MAV) which will need to be submitted together for the MGB ACO line of business.
Inputting a separate homecare authorization for each service being requested will help enhance the current provider claim and authorization process.
Rx Savings Solutions: Help your patients control their prescription drug costs
Introducing Rx Savings Solutions. Healthcare providers can’t be expected to know what every prescription will end up costing their patient at the pharmacy. That’s why Mass General Brigham Health Plan works with Rx Savings Solutions (RxSS) to give members drug pricing transparency.
How it works for patients:
- RxSS uses software that layers on top of a patient’s existing pharmacy benefit and health insurance. It analyzes claims, formularies, plan designs, and networks to find lower-cost prescription drug options that are covered by the patient’s plan.
- Nearly 70% of savings opportunities result from clinical recommendations, such as: therapeutic alternatives, dosage form changes, or generic substitutions and clones.
- Patients receive proactive notifications when there is a more affordable, equally effective option for their prescription. They are empowered, with your approval, to make the best decision for their health and budget.
What it means for providers:
Since many of the recommendations RxSS makes are clinical, providers may be required to approve the switch to a lower-cost prescription. Here’s what that means for you:
- Your office may be contacted by patients or pharmacies about these requested changes.
- Pharmacy technicians with RxSS may also contact your office—via phone or fax—on behalf of patients to obtain an approval.
- This process usually takes a few minutes, and the impact that more affordable medications can have on your patients is big.
Resources for your office:
- See the Provider FAQs flyer to get more information about RxSS and answers to frequently asked questions.
- Call 1-800-268-4476 or email support@rxsavingssolutions.com with any questions about RxSS.
Please remind your Mass General Brigham Health Plan patients to use this valuable resource. RxSS can help improve patient outcomes while decreasing the total cost of care. Their RxSS account is accessible at any time from the Mass General Brigham Health Plan member portal by visiting Member.MGBHP.org/singlesignon/rxss.
Mass General Brigham Health Plan appreciates your partnership in providing high-quality, affordable care to our members.
Non-MGB provider language services notification
Great news, Mass General Brigham Health Plan is now offering non-MGB providers access to language services. If you are a provider in need of this service, please call the LanguageLine phone line at 844-641-3553 to receive telehealth language services. Instructions on the steps to take to set up language services can be found below along with the various languages in which services are offered. Please note, this service is only for non-MGB providers and must only be used to set up language services for ACO patients. We appreciate all of the work you do and hope this new service will be beneficial to your practice.
Instructions for setting up language services
Information about the array of languages covered through LanguageLine
Multiple procedure reduction rule in progress, expected completion in February
Mass General Brigham Health Plan’s update to its multiple procedure reduction rule remains in progress and is expected to be completed by February 28, 2025. Any impacted claims processed prior to the implementation date will be reprocessed to pay appropriately.
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.
ACO Spotlight: February is National Children’s Dental Health Month
As a primary care provider, we hope you recognize the impact of discussing dental care with parents during a child’s health visits and how your support can help children access dental care.
As a provider, you can:
- Provide preventive fluoride varnish application, where appropriate, in your office.
- Encourage all children to see their dentists regularly.
- Provide appointment reminders to your patients to help ensure they do not miss appointments for preventive care.
To satisfy the ACO topical fluoride quality metric, children and young adults aged 1-20 must receive at least two topical fluoride applications as part of their dental or oral health services within the reporting year.
- Use CPT code 99188 on claims to ensure the service is captured for reporting purposes by the plan, and that you are reimbursed for the service.
For additional ACO PCP Tier 1 requirement, please see our previous publication from July 2024, Topical fluoride for children, dental or oral health services quality metric.
A searchable list of MassHealth dentists is available at provider.masshealth-dental.net/MH_Find_a_Provider#/home or members can call the toll-free MassHealth Dental Customer Service line at 800-207-5019 for help finding a dentist.
Thank you for providing the highest standards of care to our ACO members.
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, 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.MGBHP.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.
If Mass General Brigham Health Plan identifies potentially inaccurate provider information in the directory, we may reach out to your practice to validate or obtain accurate information.
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.MGBHP.org
Annual code and rate updates
Mass General Brigham Health Plan reviews its fee schedules quarterly, to ensure 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.
Consistent with prior years, Mass General Brigham Health Plan will update its Commercial/PPO physician, ambulance, drug, DME, laboratory, radiology, and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2025. Rate updates to existing CPT and HCPCS codes will occur on July 1, 2025.
With a few exceptions, Mass General Brigham Health Plan will continue to base fees on the Centers for Medicare & Medicaid Services (CMS) and MassHealth fee schedules, adjusted to achieve the contracted level of reimbursement.
Commercial/PPO physician fee schedules
- Mass General Brigham Health Plan will continue to base physician reimbursement on CMS RVU’s.
- Mass General Brigham Health Plan will continue to base drug, vaccine, and toxoid reimbursement on CMS Part B levels, as indicated on the CMS Part B drug quarterly notices. If no CMS pricing is available, drug pricing will be set in relation to average wholesale price (AWP). Reimbursement for vaccines and toxoids will continue to be updated on a quarterly basis.
Commercial/PPO outpatient fee schedules
- Consistent with prior years, reimbursement will be based on a combination of outpatient, ancillary, and surgical fee schedules.
- Mass General Brigham Health Plan will continue to base drug, vaccine, and toxoid reimbursement on CMS Part B levels, as indicated on the CMS Part B drug quarterly notices. If no CMS pricing is available, drug pricing will be set in relation to average wholesale price (AWP). Reimbursement for vaccines and toxoids will continue to be updated on a quarterly basis.
Medicaid ACO fee schedules
- Mass General Brigham Health Plan will continue to base physician reimbursement on MassHealth published rates.
- Consistent with prior years, Mass General Brigham Health Plan will update its Medicaid physician, ambulance, drug, DME, laboratory, radiology, and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2025. Rate updates to existing CPT and HCPCS codes will occur within 30 days of receipt of notification of rate changes from MassHealth.
Medicare Advantage fee schedules
- Mass General Brigham Health Plan will update its Medicare Advantage inpatient, outpatient, ancillary, professional, DME, and drug fee schedules/pricers to incorporate new codes and update rates, effective January 1, 2025.
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
Fourteen (14) 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 February 2025 here.
View the coverage summary for January 2025 new drug codes here.
View the code summary for Medicare Advantage here.
View the code summary for MGB ACO and commercial here.
Medicare drug and prior auth updates for 2025
View Medicare Part B and Part D updates here.
Formulary updates
View the formulary updates here.