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    July 2025: Utilization Management updates effective Sept. 1; retraction of recent auth policy update

    Expanding access to care for people with Down syndrome

    iStock-2164683322

    In collaboration with Mass General Brigham, members at Mass General Brigham Health Plan have access to Down Syndrome Clinic to You (DSC2U), an online service developed by Dr. Brian Skotko, MD, MPP, and the teams from the Down Syndrome Program and Lab of Computer Science at Massachusetts General Hospital, making health care accessible to everyone. 

    DSC2U brings “the best of health and wellness information about Down syndrome to caregivers and primary care physicians around the globe,” regardless of location. Read the full article.

     

     

    Contact

    MGBHP Provider Service Team can assist our provider network with inquiries and requests including the following:

    •    General provider tools and resources and/or MGBHP policies and procedures questions
    •    Member benefits & coverage
    •    Claim review/appeals requests
    •    PCP Referrals and/or Prior Authorization requirements
    •    Medical drug specialties coverage requirements
    •    Copies of relevant provider materials

    Phone: 855-444-4647
    Email: HealthPlanProvidersService@mgb.org 

    MGBHP Provider Relations works in partnership with provider offices to build and maintain positive working relationships, 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:

    Action required: Attest to your provider directory information in the Provider Portal 

    In compliance with Massachusetts law and the federal No Surprises Act, health insurance plans are required to keep provider directories current. To meet these broad provider directory requirements, Mass General Brigham Health Plan requests your assistance in verifying your information in the provider directory. 

    If you have an established process with CAQH, please continue utilizing that process, and we will receive your updates through that channel. It is essential, as part of the DOI initiative, to ensure all information remains current. 

    For facilities and groups, please visit the Provider Portal, where you can review, update, and attest to your information. Only a User Administrator can attest to this information. Every 90 days the User Administrator will be prompted to complete the attestation. If you need access to the Provider Portal, please register here. 

    If you have any questions, please contact Provider Relations at HealthPlanProvRelations@mgb.org.

    Retraction of recent authorization policy update & claims reconsideration

    We are writing to inform you of two important updates regarding authorization policies and claims processing

    1. Retraction of recent authorization policy update

    The recent policy change requiring new authorizations for the addition of CPT/HCPCS codes to existing authorizations is being retracted, effective immediately.

    Due to unforeseen IT system limitations, we are currently unable to support this change operationally. As a result:

    • You may continue to add new CPT/HCPCS codes to existing authorizations without submitting a new authorization.
    • Revisions related to units or dates remain allowable under existing authorizations.
    • The previously stated exception for IVF cancellation codes and urgent ICSI requests remains unchanged.

    We are actively working to resolve these technical issues. At this time, we anticipate the policy will be reinstated no sooner than September 1, 2025.

    2. Claims reconsideration for denials between May 15 – June 16, 2025

    We recognize that some claims may have been denied between May 15, 2025, and June 16, 2025, due to providers being unable to submit new authorizations with updated codes during this transition.

    If you experienced claim denials during this period for this reason, we are willing to reconsider those claims. Please resubmit the affected claims along with the appropriate authorization details for review.

    We appreciate your understanding and continued partnership as we work to improve our systems and processes. 

    Introducing Porter Cares

    Porter is a trusted healthcare partner now working with Mass General Brigham Health Plan. Porter provides one-time in-home assessments or telehealth assessments conducted by a physician or qualified non-physician practitioner designed to complement the care provided to the patient. It is not meant to replace any existing relationship with the patient’s PCP or specialist.

    Porter helps your patients navigate through their insurance benefits, schedule appointments with community providers, and access Federal, State, and local resources for additional support. These visits are designed to close care gaps, improve diagnostic accuracy, and connect patients to appropriate follow-up care and community resources. While Porter's support is often short-term and targeted, it serves as a valuable extension of the care team.

    For additional information, please see our FAQs or review the in-home assessment overview deck. 

    June webinar recap: Slide deck and Q&A's

    Thank you to everyone who joined us for our June webinar! Here is the slide deck and Q&A's from the webinar.

    Stay tuned for information about our next live webinar!

    Meet the Provider Relations team: Catherine Choung

    Catherine Choung

    We're thrilled to introduce you to another wonderful member of our Provider Relations team! This month, meet Catherine Choung, our Provider Network Account Executive. Catherine has been a valued part of Provider Relations for over 10 years. She was previously a Claims Home Infusion Specialist and a Claims Reviewer Team Lead within the organization.

    Catherine covers our Ancillary Network which includes:

    • ART/IVF
    • Labs
    • Limited service clinics
    • Radiology
    • Sleep
    • Urgent care
    • DME
    • Ambulance
    • Ambulatory surgery centers (ASC)
    • Dialysis
    • Home infusion
    • Hospice
    • Home health
    • Skilled nursing facilities/rehabs
    If you're in Catherine's network area and would like to get in touch with her, please email cchoung1@mgb.org.

    CMS requirement: Submit Form CMS-2552-10 for Transplant when billing for Rev 81X

    Mass General Brigham Health Plan's Medicare Advantage product line follows the CMS requirements for Transplant. The CMS requirement is as follows: Submit Form CMS-2552-10 for Transplant when billing for Rev 81X. 

    Narcan/Naloxone billing requirement effective July 1

    Beginning 07/01/2025, Mass General Brigham Health Plan requires facilities to bill for Narcan/Naloxone dispensed to commercial members in the facility setting on the same UB claim form as all other services performed during the same episode of care. A separate, unbundled reimbursement will be made if the following billing requirements are met:
     
    Criteria
    •  HCPCS code: J3490
    •  Revenue code: 636
    •  Modifier: HG
    •  NDC code: 11-digit NDC code
    •  LOB: Commercial Products

     

    AllMed to support utilization management and appeal reviews beginning Sept. 1

    Mass General Brigham Health Plan will be using an additional independent review organization, AllMed, starting on 9/1/2025. AllMed will be available to the plan to assist with review of cases where external subject matter expertise or same/similar specialty is necessary.

    Utilization Management updates – Effective September 1, 2025

    We’re making several important updates to our Utilization Management processes to improve efficiency and clarity for providers. Please review the following changes:

    1. Home care authorization submission updates
    • Mass General ACO members only:
      Skilled Nursing and Medication Administration Visits (MAVs) must be submitted under a single authorization.
    • All other lines of business:
      Skilled Nursing visits must continue to be submitted on a separate authorization.
    • All lines of business:
      Physical Therapy and Home Occupational Therapy requests must be submitted on separate authorizations.
      The provider portal will be updated to improve visibility into approved and denied units.

    Please note: Training will be offered in August prior to implementation.

    2. Global authorizations for surgical procedures
    • Surgical authorizations will no longer be split into an authorization for the surgeon and one for the facility. One authorization will be created for both the
      surgeon and the facility.
    • The submission process on the provider portal remains unchanged.
    • Approval and/or adverse determination letters will now be sent to the requesting surgeon, not the facility.

    3. Annual reauthorization requirement for ongoing services
    •  For outpatient prior authorization requests, a new prior authorization must be submitted one year from the original request date.
    •  Example: If the initial request for home care services was submitted on November 28, 2024, a new authorization request is required by November 27, 2025.
    •  This applies only to prior authorizations with no code changes.

    4. Provider Portal update: Service start and end dates
    Please note the following update regarding the entry of service dates on the Provider Portal:

    •  The service end date will be automatically populated only for the following Outpatient services:
    •  Outpatient surgeries (e.g., surgical day care)
    •  High-tech radiology
    •  Enteral services
    •  Specialty referrals
    •  For all inpatient services and outpatient services not listed above, you will need to manually enter the Service End Date.

    5. Provider Portal enhancement
    Enhancements will be made under the Authorization/Service Lines section. You will now be able to view:

    •  A description of the authorization request
    •  Dates of service
    •  Number of units/days approved
    •  Units/days used

    These updates are designed to provide greater transparency and improve tracking of authorization details.

    Thank you for your continued partnership!

    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.

    ACO spotlight on maternal health: Decreasing unnecessary cesarean deliveries

    Mass General Brigham Health Plan is collaborating with MGB hospitals on a new health equity performance improvement initiative titled 'Reducing Inequity in Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Deliveries.'

    Safe reduction of nulliparous, term, singleton, vertex (NTSV) cesarean deliveries, or cesarean deliveries for patients with low-risk pregnancies, is an essential part of advancing high-quality, equitable maternal health outcomes.[i] While cesarean deliveries are at times medically necessary, they are associated with increased health risks to birthing people compared to vaginal births including increased risk of hemorrhage, venous thromboembolism, infection, anesthesia complications, and complications in future pregnancies such as uterine rupture and abnormal placentation.[ii]

    To support the safe reduction of NTSV cesarean deliveries, providers can explore the two evidence-based educational resources listed below.

    [i] Calculation and Coding of Cesarean Birth Rates | ACOG. (n.d.). Retrieved February 13, 2025, from https://www.acog.org/news/news-articles/2024/07/calculation-and-coding-of-cesarean-birth-rates

    [ii] Crespo, F. A., & Verma, U. (2022). High Primary Cesarean Section Rates: Strategies for Improvement. In Joint Commission Journal on Quality and Patient Safety (Vol. 48, Issue 11, pp. 617–624). Joint Commission Resources, Inc. https://doi.org/10.1016/j.jcjq.2022.07.005

    Webinar and resources: Cultural competency training for providers

    Visit Health Equity Resources on the Provider Resources page at  https://massgeneralbrighamhealthplan.org/providers/education to explore free online training options regarding cultural competency.  There is also an opportunity to earn credits depending on the program. According to the training offered by the Department of Health and Human Services, “the e-learning program will equip you with the knowledge, skills, and awareness to best serve all patients, regardless of cultural or linguistic background."

    In addition, there is a webinar opportunity regarding Limited English Proficiency (LEP) using the link provided below. LEP is used to define a person’s narrow ability to read, write, and/or speak English. Approximately 8% of the United States’ population (accounting for 25.7 million people) have LEP. Of this amount, 853,374 reside within the Commonwealth of Massachusetts. Studies show that LEP patients often receive a lower quality of care when compared to fluent/native English speakers. The most common reasons for lower quality of care among LEP patients include communication barriers, cultural differences, and bias. Due to this, LEP is associated with increased medical errors, lower patient adherence, worse clinical outcomes, and poor patient satisfaction. Despite these disparities, there are ways in which clinicians can mitigate these effects and provide high-quality care for patients experiencing LEP. The video linked below is an educational webinar that offers insight on the steps clinicians can take to improve healthcare delivery for LEP patients. We hope you find this webinar helpful.

    Watch now: https://www.qualityinteractions.com/hubfs/Share/MGB/QI_LEP_Webinar.mp4

    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 how 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 the work you do and hope this new service will be beneficial to your practice.

    Instructions for setting up language services

    List of languages covered through LanguageLine

    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. 

    Select a designated Provider Portal User Administrator

    Please ensure your practice has a designated User Administrator for the Mass General Brigham Health Plan Provider Portal. The User Administrator is responsible for managing user requests for your practice and will be required to attest to your practice information via the Provider Portal. Designating a User Administrator will ensure timely access for registered users to utilize the Provider Portal.

    Please complete and email the User Administrator form to HealthPlanProvRelations@mgb.org. The User Administrator will need to register for an account on the Provider Portal if they do not already have one. Please see additional helpful information on how to register for the Provider Portal below. 

    Frequently asked questions about the Provider Portal

    Q: How do I register for the portal?
    A: It only takes about five minutes to register for the Provider Portal. Have your practice's tax ID number handy before you start.

    • Register now
    • Access requests are managed by the User Administrator for your practice. Contact your User Administrator if you have any questions.

    Q: How do I become an administrator?
    A: Please complete the User Administrator form. When your portal account is activated, you can request User Admin access under the Manage Account link on the portal home page.

    Q: How do I contact customer support for the Provider Portal?
    A: For registration support, technical issues, or other questions and concerns, contact HealthPlanprweb@mgb.org

    Q: What do I do if my account or password expires?
    A: Your login credentials will expire and be deleted if you do not log in for 180 consecutive days. If your account is deleted, you will be required to re-register.

    If you forget your password, you can reset it by clicking the "I Forgot My Password" link within the Provider Portal login page. You will be asked to provide a contact phone number and answer a security question.

    Q: Who do I contact with questions regarding the Provider Portal?
    A: You can contact HealthPlanprweb@mgb.org

    Coverage for opioid antagonists

    Effective 7/1/2025, opioid antagonists, such as Narcan®’, are covered at $0 cost share under the medical benefit when provided by a facility. Deductibles do still apply to HSA-qualified high-deductible health plans. This change is in addition to our current pharmacy benefit coverage of Narcan at $0 cost share.

    This is in accordance with Chapter 285 of the Acts of 2024, to expand treatment and support for substance use disorder in the Commonwealth of Massachusetts.

    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.

    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 to help ensure 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

    Primary Care Sub-Capitation Code updates

    MassHealth is making the following changes to the Primary Care Sub-Capitation Code Set:

    Following their deletion by the American Medical Association, codes 99441, 99442, and 99443 have been removed from the Code Set and are being replaced by 98008-98016, a set of newly created audio-only visit codes 98000-98007, audio-video visit codes, are also being added to the Code Set.   

    The new codes have been retroactively added to the code set effective 1/1/25; no further action is required from providers as claims submitted for the new codes on this date or after will be reviewed/reprocessed accordingly. Mass General Brigham Health Plan’s system and Primary Care Sub-Capitation Resource Guide have been updated to reflect these recent codes updates.

    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.

    Multiple procedure reduction rule in progress; expected completion August 1

    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.

    Medical policy updates

    Twelve (12) 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 MGBHP.org/providers/medical-policies and select the policy under the medical policy listings.

    Drug code and code updates

    View code updates for July 2025 here. 

    Formulary updates

    View the formulary updates here.

    Medicare pharmacy updates

    View the Medicare pharmacy updates here.

     

    Related Articles

    January 2025: New Provider Portal enhancements; Cultural competency training and resources
    April 2025: Annual CAHPS survey; register for the spring regional provider meeting
    June 2025: Men's Health Month; attest to your provider directory info in the Provider Portal beginning July 1