July 2024 - Urgent care center reimbursement, pediatric preventive visits and screenings

Improving health outcomes among at-risk populations

“Our mission is to dismantle the barriers, systems, and actions inside and outside our walls to provide excellent medical care and equity for all,” said Dr. Elsie Tavares, MD, MPH, Chief Community Health and Health Equity Officer at Mass General Brigham and a leading expert in community health equity and health disparities.

“We’ve made a huge commitment to influence the areas of health inequities—with as much rigor as we put towards research, medical innovation, and clinical services. And if we don’t have a robust way of measuring our inequities, then we don’t have a robust way of designing a precise solution for our problems.” Explore the areas that Mass General Brigham is focusing on to improve health equity among at-risk patient populations. 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
• Cultural Sensitivity Provider Survey coming week of July 22
• MassHealth RY23 Encounter Data Deadline Update
• Provider resource: Preventive services grid
• Important information regarding Steward Health Care
• ACO spotlight: Pediatric preventive health visits and screenings 
• Health Quality and Equity Strategic Plan
• New payment guidelines for transplants, clinical trials, and dialysis
• MassHealth members eligible for free doula services
• Coming soon: Submit new claims through the provider portal
• Improving call wait times
• Hospital inpatient utilization report
• ACO Bite-Sized Bits: Childhood and adolescent immunizations
• Topical fluoride for children, dental or oral health services quality metric
• Help us keep directory information up to date
• Tips for submitting a PCP change in the provider portal
• Genetic testing requests with eviCore Healthcare
• Annual updates to physician and outpatient fee schedules
• Medical policy updates
• Medicare provider notification
• Drug code and code updates
• 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 will reimburse 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 percent 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 waiving 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. 

Cultural Sensitivity Provider Survey coming week of July 22

The Cultural Sensitivity Provider Survey will be going live during the week of July 22. Please keep a lookout for the survey and accompanying letter being sent to providers and office managers via mail by our vendor Press Ganey. The Cultural Sensitivity Provider Survey is going to be used to 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. Thank you for all of your hard work in helping MGB Health Plan to better meet the diverse needs of its members. 

MassHealth RY23 Encounter Data Deadline Update

MassHealth is aware that health plans and providers are working closely to meet the RY23 encounter data submission deadline.  Mass Health acknowledges that this process can often be challenging and therefore has extended the final paid date from original deadline of 7/31/24 to 8/31/24.

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.

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 need support before July 1 or 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 have been closely monitoring the situation with Steward Health Care, including its recent announcement about filing for bankruptcy. While the bankruptcy process continues, our members can access care at Steward Health Care facilities, including hospitals, medical centers, and physicians’ offices. These facilities remain open, and we are encouraging our members to keep their appointments with Steward providers.

We are committed to ensuring that our members have access to care and continue to monitor this process.

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).

ACO spotlight: Pediatric preventive health visits and screenings 

As the summer is upon us, Mass General Brigham Health Plan would like to take this opportunity to highlight the suite of pediatric preventative services that are covered under our MGB ACO Medicaid program. During these next few months, lots of families will be seeking their child’s preventative health visits to prepare for summer camps, sports activities and the next school year, so here is a reminder of how to access information regarding covered services, and how we can help support our providers in the care of all pediatric members.

Under the Mass Health program, MGB Health Plan covers a number of services under the Mass Health Standard Plan. Under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) and Preventive Pediatric Health Care Screening and Diagnosis (PPHSD) regulations Early and Periodic Screening, Diagnostic, and Treatment | Medicaid Mass Health requires primary care providers to offer EPSTD and PPHSD screens for members under the age of 21 in accordance with the EPSDT Services Medical Protocol and Periodicity schedule found here. States are required to provide comprehensive services and furnish all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, based on certain federal guidelines. EPSDT is made up of many important screening, diagnostic, and treatment services. At these important visits, children may be screened forboth physical and behavioral health conditions, and if the screens show that there might be a problem, MassHealth reimburses for certain further assessment, diagnosis, and treatment services.

MGB Health Plan endorses the Massachusetts Health Quality Partners pediatric Preventative Health Guidelines which can be found on our website at Provider resources | Mass General Brigham Health Plan which also contain a number of other valuable resources including links to our Optum Behavioral Health resources. These guidelines outline preventative health and screening recommendations throughout all ages and are authored in conjunction with both pediatric and family practice providers and health plan clinical representation drawing on the most up to date evidence and best practice guidelines.

Our Care Management programs can also help support your members. For information regarding all our programs as well as other important resources, please visit our provider resource page at Providers | Mass General Brigham Health Plan.

Health Quality and Equity Strategic Plan

Learn about our strategic plan to improve health quality and equity for Mass General Brigham Health Plan (MGBHP) members.

Defining health equity

The MGBHP defines health equity as the opportunity for everyone to attain their full health potential, regardless of their social position (e.g., socioeconomic status) or socially assigned circumstance (e.g., race, gender identity/gender expression, ethnicity, disability status, religion, sexual orientation, geography, disability, language, etc., as defined by the Medicaid contract).

Our health quality and equity goals

Over the next four years, the MGBHP hopes to achieve the following goals related to health quality and equity:

• Increase completeness and accuracy of members race, ethnicity, language, disability sexual orientation and gender identity (RELD/SOGI) data.
• Establish a culture of equity through the provision of staff trainings on health equity, implicit bias, and anti-racism.
• Continue assessing and improving our provider network capacity to address cultural, linguistic and accommodation needs of our MGBHP membership.
• Achieve NCQA health equity accreditation for the MGBHP.
• Create culturally and linguistically appropriate health programs to address disparities in the following areas:
  
      ○ Chronic conditions (e.g., diabetes and blood pressure management),
      ○ Mental health services and substance abuse especially for youth and individuals of color.
      ○ Access to care especially for people of color and LGBTQ+ community.
      ○ Socio-determinants of health, such as food insecurity.

Some of the interventions that we are in the process of implementing to achieve the goals referenced above are as follows:

• Training the MGBHP provider network on disability competency care (DCC) by the end of Q3 2024.
• Implementing a survey that assesses the cultural sensitivity of the       MGBHP network providers.
• Training the MGBHP provider network on the administration of care to patients with limited English proficiency (LEP) by end of Q3 2024. The training will offer best practices for how providers can work effectively with translators to improve healthcare outcomes for LEP patients.
• Address diabetes health disparities by implementing or continuing with the following initiatives:

             ● Connecting MGBHP members with community resources such as food pantries, meal services, and mobile medical vans.

New payment guidelines for transplants, clinical trials, and dialysis

We're excited to share that we have just introduced new payment guidelines for transplants, clinical trials, and dialysis. View the updated guidelines here. If you have any questions regarding these payment policies, feel free to reach out to our provider services team at 855-444-4647.”

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.

Coming soon: Submit new claims through the provider portal

Launching this month, you can submit new claims through the provider portal. Simply visit Provider.MassGeneralBrighamHealthPlan.org, select Submit a claim beneath the portal navigation bar, and follow the onscreen instructions to complete the submission. 

Key points to remember

• Submissions through the portal are limited to new claims only.
• Only attachments for claims with invoices will be accepted.
• Double-check all claims for accuracy before final submission.
• Incomplete claims will prompt a notification by mail.
• Claims submitted after 5pm EST will be processed the following business day.
• Please submit only one claim at a time to ensure efficient processing.

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.

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: Childhood and adolescent immunizations

Childhood Immunizations

This ACO quality metric measures the percent of children turning age 2 in the measurement year who have received all recommended vaccines including 2 Flu shots.

Flu shots are the most frequent gap for this measure. The CDC recommends that everyone 6 months and older get a seasonal flu vaccine. This is especially important for young children because they are at increased risk of getting severe illness from the flu. Reference: CDC - Protect Against Flu.

Tips to Improve Patient Care/ HEDIS Rates:

• MGB Health Plan has an ongoing text message campaign for MGB ACO members reminding parents about the importance of their child receiving immunizations by their second birthday.
• Educate parents on the benefits of getting all recommended immunizations for their children. The CDC has patient education materials (Immunization Schedules for You and Your Family | CDC) you can print and share.
• Submit a bill for all antigens given with the appropriate modifier, if applicable (even if State supplied vaccine is used).
• Document exclusions and vaccine refusal in the medical record.
• Visit CDC Immunization Schedules to download printable immunization schedules.

Adolescent Immunizations

The most frequent gap for adolescent immunizations is the Human Papillomavirus (HPV) vaccine. All children who are 11 or 12 years old should get two shots of HPV vaccine 6-12 months apart. This vaccine protects against cancers caused by infection by HPV, a common virus that infects about 1 million people, including teens, each year. HPV infection can cause cervical, vaginal, and vulvar cancers in women and penile cancer in men. HPV can also cause anal cancer, cancer of the back of the throat (oropharynx), and genital warts in both men and women. Reference: CDC - HPV Vaccine Information

Tips to Improve Patient Care/ HEDIS Rates:

• Educate parents on the benefits of getting all recommended immunizations for their children.
• HPV series must be completed for all children turning age 13 in the measurement year along with 1 meningococcal, 1 Tdap immunization and annual flu shot.
• Bill all antigens and appropriate modifiers provided in accordance with the MGB Health Plan payment guidelines (even if State supplied vaccine is used) available here.
• Document exclusions and vaccine refusal in the medical record.
  

Topical fluoride for children, dental or oral health services quality metric

The American Academy of Pediatrics states that “dental caries remains the most common chronic disease of childhood in the United States. Caries is a largely preventable condition, and fluoride has proven effectiveness in caries prevention.”  Good oral health contributes to overall health. Reference:     https://publications.aap.org/pediatrics/article/146/6/e2020034637/33536/Fluoride-Use-in-Caries-Prevention-in-the-Primary

For ACO members, MassHealth includes this topical fluoride quality metric:

• Percentage of children aged 1–20 years who received at least 2 topical fluoride applications as dental or oral health services within the reporting year

Additionally, all ACO PCPs attested to providing the following in the Tier 1 requirements:

• Practices serving Enrollees 21 years of age or younger shall: Assess the need for fluoride varnish at all preventive visits from six (6) months to six (6) years old, and, once teeth are present, must provide application of fluoride varnish on-site in the primary care office at least twice per year for all children, starting when the first tooth erupts and until the patient has another reliable source of dental care.
• Remember to bill CPT code 99188 to ensure the service is captured in quality and you are paid for the service.

PCP Tier 1 requirement for all patients:  

• Oral health screening and referral: conduct an annual (every 12 months) structured oral health screening for attributed patients.
• Retain and provide to patients (and/or their parents/caregivers) a list of local and reasonably accessible oral health providers who are within the MassHealth network for their particular patients. A searchable list of MassHealth dentists is available at provider.masshealth-dental.net/MH_Find_a_Provider
  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, 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 currently partners with eviCore Healthcare for genetic testing requests. Beginning on 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.

Annual updates to physician and outpatient fee schedules

Mass General Brigham Health Plan reviews its physician and outpatient 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.

Consistent with prior years, Mass General Brigham Health Plan updated its Commercial, PPO, and Medicare physician, ambulance, drug, DME, laboratory, radiology, and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2024. 

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

• Rate updates to existing CPT and HCPCS codes will occur on July 1, 2024.
• Mass General Brigham Health Plan will continue to base physician reimbursement on CMS RVU’s & anesthesia conversion factor.
• 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.
• Mass General Brigham Health Plan will continue to base DME reimbursement on the CMS DME POS/PEN fee schedules.

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.
• Mass General Brigham Health Plan will continue to base DME reimbursement on the CMS DME POS/PEN fee schedules.

Medicaid Fee Schedules

• Mass General Brigham Health Plan will continue to base physician reimbursement on MassHealth published rates, where published rates exist. 
• Consistent with prior years, Mass General Brigham Health Plan updated its Medicaid physician, ambulance, drug, DME, laboratory, radiology, and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2024.  Rate updates to existing CPT and HCPCS codes will occur within 30 days of receipt of notification of rate change from MassHealth.

Medicare Advantage Fee Schedules

• Mass General Brigham Health Plan updated its Medicare Advantage inpatient, outpatient, ancillary, and professional fee schedules/pricers to incorporate new codes and update rates, effective January 1, 2024. 

Medical policy updates

Six (6) 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 July 2024 here. 

Formulary updates

View the formulary updates here.