Nurse care managers can improve patient outcomes
People who’ve had a recent surgery or live with a chronic condition are often surprised to get a call from a nurse care manager (or case manager) from their health plan. A common reaction is, "Who is this person, and why are they calling me?"
As Colleen Morley-Grabowski, DNP, RN, CMM, writes for the Case Management Society of America’s Blog, “By focusing on patient-centered care, case managers ensure that each patient’s needs, preferences, and goals guide their healthcare journey. Case managers bridge communications gaps, resolve barriers to care, and advocate for their patients.” 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 beginning July 1
- Men's Health Month: Focusing on heart disease
- New inbox for urgent COB provider requests
- New CPT/HCPCS code additions require new authorization
- Webinar recording: Behavioral Health for Medicaid Patients
- Ancillary professional providers can contact Provider Relations for assistance
- Coverage for opioid antagonists
- Help us keep directory information up to date
- Massachusetts Alt EVV live training opportunities
- Primary Care Sub-Capitation Code updates
- Update to prior authorization requirement for observation stays
- MassHealth RY24 encounter data deadline is July 31
- Multiple procedure reduction rule in progress, expected completion August 1
- Medical policy updates
- Drug code and code updates
- Formulary updates
Action required: Attest to your provider directory information in the Provider Portal beginning July 1
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.
Men's Health Month: Focusing on heart disease
Men's Health Month serves as a platform to increase awareness regarding heart disease, which is a primary cause of mortality among men. The American Heart Association (AHA) and various other organizations utilize this period to advocate for screenings, healthy lifestyle choices, and discussions surrounding heart health.
Hypertension is a significant risk factor for heart disease. It is essential for healthcare providers and medical personnel to implement the following best practices for each patient undergoing a blood pressure assessment.
Best practices:
- Document blood pressure readings at every visit.
- Allow patients to rest for at least five minutes before taking blood pressure.
- Blood pressure readings that are 140/90 mmHg or greater should be retaken.
- Schedule follow-up visits for blood pressure control after diagnosis or medication adjustment.
- Make sure the appropriate size cuff is used.
- Ensure the patient’s arm is supported and at heart level. If the patient’s arm is below heart level and unsupported, this position can elevate the measured blood pressure by 10-12 mmHg.
- Educate patients about the risks of uncontrolled blood pressure.
Click the link below to review the correct medical codes used to report blood pressure readings on your claim submission.
Billing codes to support hypertension
New inbox for urgent COB provider requests
A new inbox has been established for providers to address urgent COB issues. We request providers still submit their requests through correspondence, if possible, and use this email address for priority follow up inquiries.
For urgent issues, please email: MGBCOBServicesHealthPlan@mgb.org
New CPT/HCPCS code additions require new authorization
Beginning in May, adding a new CPT/HCPC code to an existing authorization will now require a new authorization. This update ensures accurate tracking of receipt dates and compliance with regulatory requirements. Revisions to existing authorizations are still allowed if the changes are related to units or dates.
Exception: The only exception to this are for IVF cancellation codes and urgent ICSI requests. These may be documented in the remarks section of the authorization, with supporting documentation submitted to allow for processing under the original authorization.
We appreciate your cooperation and understanding as we implement this change to support consistency and timeliness in authorization processing.
Webinar recording: Behavioral Health for Medicaid Patients
The recording for last month's webinar, Behavioral Health for Medicaid Patients, is now available. Please reach out to Keri Sperry (ksperry@mgb.org) for access to the recording.
Overview of topics:
- Welcome and Introduction to Behavioral Health Integration in Primary Care – Nina Jain, MD, MBA
- Maximizing the Use of Community Behavioral Health Centers – Curtis Wittmann, MD
- Behavioral Health Community Partners – Katherine Schiavoni, MD
- MGB's Medicaid Social Worker Program — Emily Marion
- Health Related Social Needs Supplemental Services Referrals — Katinka Canning
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.
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.
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
Massachusetts Alt EVV live training opportunities
If your provider agency has chosen to utilize an Alternate Electronic Visit Verification (Alt EVV) system, we invite you to attend one of three live training sessions tailored specifically for you. All three sessions will review the exact same content. Please join whichever session works best for you. We encourage all Alt EVV Providers and their Alt EVV Vendors in Massachusetts to attend this training. This training is not recommended for providers registered for the state-sponsored EVV system, Sandata.
Register using the links below:
Option 1 - June 11 – 9:30 a.m. ET
Option 2 - June 12 – 3 p.m. ET
Option 3 - June 17 – 12:30 p.m. ET
Note: The live sessions will be recorded; parts of which may be used as an EVV training resource.
This training will walk you through how to successfully connect your current Alt EVV platform to the Sandata Aggregator and ensure you’re on your way to EVV success as part of the 21st Century Cures Act. Investing one hour now can set you up for long-term success and save you hours later.
Here’s what you’ll walk away with:
- Steps to prepare your EVV data for submission
- Common issues and how to avoid them
- Best practices for ensuring claims validate successfully
Contacts and resources
View the Massachusetts Detailed Instructions for Onboarding for a step-by-step guide on how to get started.
View the recordings and materials, including Frequently Asked Questions, from all previous Town Halls at Sandata On-Demand. Check out the comprehensive Questions and Answers from the Commonwealth to help navigate EVV policies.
For technical help in using the EVV system, please Submit a Request via Sandata On-Demand. You may also call the Customer Support line at 833-511-0164.
For general questions about the Massachusetts EVV program, please email EVVfeedback@Mass.gov. You can also visit the MA-EOHHS EVV website for more information.
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 Primary_Care_Sub-Capitation_Resource_Guide.pdf have been updated to reflect these recent codes updates.
Update to prior authorization requirement for observation stays
To support timely access to care and reduce administrative burden, Mass General Brigham Health Plan is removing the prior authorization requirement for observation stays for our Medicaid and Commercial members. Effective 5/1/25, observation stays up to 48 hours (two calendar days) will be covered without prior authorization. Providers should follow standard prior authorization procedures for length of stay’s greater than 48 hours and an inpatient admission is required. Inpatient hospitalization requests require a separate authorization.
This change is designed to streamline the care process while ensuring proper claims processing. Providers should continue to follow standard clinical documentation and billing practices. Thank you for your continued partnership in delivering quality care to our members.
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
Nine (9) 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
Updated 6/12/25: View code updates for June 2025 here.
Formulary updates
View the formulary updates here.