March 2024 - Tips for Prior Authorization Requests, Programs Addressing Social Determinants of Health

Featured story: 5 tips for submitting prior authorization requests




What services require prior authorization? Where can I submit a request? How do I check the status of an authorization request? We hear these questions often. To help you access all the answers in one place, we’ve put together a list of helpful tips for providers and administrators. Continue reading to learn more about how to submit a prior authorization request with Mass General Brigham Health Plan. Read the full article.






In this issue:

Responding to the Change Healthcare cybersecurity incident

Read our response to the Change Healthcare cybersecurity incident and learn where you can find additional information.

Video - Provider portal overview

Take a tour of the Mass General Brigham Health Plan Provider Portal. Learn how to access member rosters, process a PCP change, and more.

View on YouTube (full screen)

Spotlight: Programs addressing social determinants of health

Managing social determinants of health (SDH) is crucial for improving patient care and removing disparities in health outcomes. This month, we're spotlighting two programs that are making a big impact on helping manage social determinants of health: MGB Medicaid ACO Community Partners and Flexible Services

What is the MGB Medicaid ACO Community Partners program?

Community Partners is a care management program for complex patients with MassHealth ACO insurance that provides behavioral health and long-term care supports delivered in collaboration with subcontracted community partners organizations (“CPs”).

What can the program do to help my patients?

  • Behavioral Health (BH) CP:

Serves patients > 18 years with behavioral health conditions, severe mental illness, and substance use disorder. BH CPs can coordinate patients’ physical and behavioral health care and provide community resource/navigation support such as finding community-based mental health or substance use treatment, crisis and intensive services (PHP/IOP), wrap-around services, obtaining cell phones or tablets, and specific services for individuals with justice system involvement or homelessness.

  • Long-term Services and Supports (LTSS) CP:

Serves patients > 3 years with disabilities, chronic illnesses, and long-term care needs. LTSS CPs can assist with finding DME, home health or PCA services, adult day health or day habilitation, and can provide support for health-related social needs.

How can I refer my patients to the program?

Eligibility Requirements:

For both BH and LTSS, patients must be enrolled in MGB MassHealth ACO and must have an established MGB PCP.

  • For BH, the patient must be age 18-64 and have severe mental illness or substance use disorder needs.
  • For LTSS, the patient must be age 3-64 with chronic illness, disability, or other long-term care needs.

How to refer a patient:

Search for Epic referral order under “Ambulatory Referral to MGB Community Partners Program” and complete form with patient’s information. Program enrollment occurs on the 1st of every month following the placed referral. Please reach out to for more information.

What is the Flexible Services Program?

The Flexible Services Program is a focused Executive Office of Health and Human Services (EOHHS) program testing whether Accountable Care Organizations (ACOs) can improve members’ health outcomes and reduce Total Cost of Care (TCOC) and health disparities through targeted evidence-based program that address certain subset of eligible members’ Health Related Social Needs (HRSNs). MGB has a limited budget to provide Flexible Services to a small percentage of Medicaid ACO members. View the Flexible Services Program Guidance Document.

Who can receive Flexible Services?  

To be eligible for Flexible Services, an individual must be a MassHealth member enrolled in the MGB ACO. Members must have at least one Health Needs-Based Criteria and must also meet at least one risk factor.

Health Needs-Based Criteria:

  1. Behavioral Health Need; or
  2. Complex Physical Health Need; or
  3. Activities of Daily Living (ADL)/ Instrumental Activities of Daily Living (IADL) Needs; or
  4. Repeated ED use; or
  5. High risk pregnancy

Risk Factors:

  1. Experiencing homelessness;
  2. At risk of experiencing homelessness; or
  3. At risk for nutritional deficiency or imbalance due to food insecurity

What services are available?

Members who meet eligibility criteria may receive services for housing support, nutritional support or both, for up to 6 months. Nutritional services include, nutrition education, medically tailored meals, food/produce boxes and food vouchers. Housing services include housing search and stabilization and home modifications. Eligibility does not guarantee enrollment.

Has anything changed with Flexible Services?

In 2024, Nutritional Support Services are administered by Foodsmart-the nation’s largest provider group of telehealth registered dieticians. Foodsmart has contracted with Community Servings, Just Roots, About Fresh, Fresh Food Generation and the Western Mass Food Partnership to create a Hub and Spoke model providing members with up to 6 RD visits and a patient centered care plan. View Foodsmart FAQs.

Where can referrals be sent to?

Referral volume is limited and allocations are managed by Care Management teams at each Regional Service Organization. Please reach out to the Flexible Services inbox at if you have questions about who to contact to place a referral.  View the Medicaid ACO Flexible Services Program Eligibility and Referral Process.

Home Health providers: Medicare Advantage billing guidelines 

For patients with Medicare Advantage, Home Health providers should follow the CMS billing guidelines below:

Medicare Claims Processing Manual (

  • 40.1 for the submission of the NOA (notification of admission)
  • 40.2 for the Rev code, type of bill, HIPPS Code and billing increments


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 or by submitting a Provider Change via the Provider-Enrollment-Form to Mass General Brigham Health Plans Provider Enrollment Team by email at

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



Mass General Brigham Health Plan’s drug fee schedules to be updated
Mass General Brigham Health Plan reviews its drug 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.

The next update will occur on April 1, 2024. Changes may involve both new and existing CPT and HCPCS codes and will include the planned quarterly update to physician administered drugs, immune globulin, vaccine and toxoid fees.


Complete a DAR with appeal submission

As a reminder, providers submitting appeals on behalf of members MUST also include a completed Designation of Authorized Representative form with the appeal.  If the completed form is not received, communication of the outcome of the appeal will be to the member only.  For your convenience, the Designation of Authorized Representative form can be found online via the Mass General Brigham Health Plan provider portal.  The form is also located within the member and provider resource section of the Mass General Brigham Health Plan ACO website at  MGB ACO | Mass General Brigham Health Plan.”


MassHealth Doula Services Program

As of December 8, 2023, MassHealth now covers doula services, subject to MassHealth coverage limitations, for MassHealth members while they are pregnant, during delivery, and up to 12 months after delivery.

MassHealth covers doula services provided by individual doulas practicing independently and doula group practices. Individual doulas and doula group practices need to enroll with MassHealth to provide services to MassHealth members and receive payment. Doula group practices cannot be part of a hospital, other group practice, or other healthcare facility. 

This service is being administered directly by MassHealth. For more information, please visit  


Annual Mental Health Wellness Exams


Per MA DOI Bulletin 2024-02, we will cover an annual Mental Health Wellness Exam when billed under the medical benefit effective 4/1/2024 as follows: 
Diagnosis Code: Z13.30, Encounter for screening examination for mental health and behavioral disorders, unspecified
Service Code: 90791, Psychiatric diagnostic evaluation
Modifier: 33, Preventive Services: When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.
Frequency Limit: Annual
Services are provided at no member cost sharing except if the member is enrolled in an HSA qualified health plan (plan name includes the word ‘HSA’).
Mass General Brigham Health Plan’s Behavioral Health partner, Optum, will update our behavioral health providers via Provider Express. 



Home health care - prior authorization requirements 


Mass General Brigham Health Plan reimburses contracted Home Health Care agencies for home health care service provided to a member with an approved home health care plan. Various services and procedures require referral and/or prior authorization.


To determine if a service or procedure requires a referral and/or prior authorization, please refer to the referral and prior authorization guidelines.


Additional resources

  • The medical policy for home health care can be found here
  • Provider payment guidelines for home health care can be found here




Temporary waiver of authorization for post-acute facilities

Mass General Brigham Health Plan is waiving prior authorization requests from January 9, 2024 until April 1, 2024 for patient transfers from acute care hospitals to sub-acute care facilities and rehabilitation facilities. This applies to initial admission to the sub-acute and/or rehabilitation. This is in support of the recent directive from the Massachusetts Executive Office of Health and Human Services (EOHHS).

Notice of Admission (NOA)

Notifications should be submitted by the respective Skilled Nursing and Acute Rehabilitation facilities within 24 hours of admission and updates provided a minimum of every 5 days to support discharge planning. 

Concurrent review and retrospective review will proceed (if notification occurred) to determine appropriateness of level of care.

Included in this waiver

  • Medicaid, Commercial and Medicare lines of business
  • INN providers
  • OON providers within Massachusetts

Excluded from this waiver

  • Long Term/custodial care
  • Out of network providers outside of Massachusetts

Commercial 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 returned 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 and behavioral health. 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. The MA DPH establishes rates for Early Intervention and Early Intensive Behavioral Intervention.
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.


Response to ED Boarding Crisis

Mass General Brigham Health Plan complies with regulatory guidance to ensure Hospitals are reimbursed for behavioral health crisis evaluations and stabilization services provided in the Emergency Department in response to the ED Boarding crisis.

This applies to:

  • Commercial members, for dates of service 11/01/2022 and forward per MA DOI Bulletin 2022-08.

  • Medicaid members, for dates of service 01/03/2023 through 09/30/2023, per Mass Health guidance including MCE Bulletin 93 published November 2022.
  • Medicaid members, for dates of service 10/01/2023 and forward, per the MA Inpatient Acute General RFA effective 10/01/2023.

Mass General Brigham Health Plan complies with regulatory guidance to ensure Hospitals are reimbursed for behavioral health crisis evaluations and stabilization services, crisis management, recovery support navigators and the initiation of medication treatment for Opioid Use Disorders in the ED per the MA Inpatient Acute General RFA effective 10/01/2023.  

Provider payment guidelines | Mass General Brigham Health Plan


ACO Bite-sized Bits

Live webinar on developing skills for addressing racism and discrimination in healthcare

MassHealth expects providers to undergo training on diversity and inclusion. MGB is offering mutiple sessions for 'We Are Upstanders': Developing skills for addressing racism and discrimination in healthcare. In a live, virtual session with a facilitator and colleagues, this introductory course provides employees with greater understanding and confidence to address racism and other acts of discrimination in the work environment, whether from patients, their visitors/family members or other staff. Through discussions of techniques, case studies and policy, participants will develop skills for recognizing when to intervene to disrupt or respond to racism/discrimination, assessing their options for how to act and enacting next steps. Enroll in HealthStream. Check back each month for more dates through June 2024. Questions? Contact Jenna Faltas


We welcome patients or family members to join the MGBHP Medicaid ACO Patient Family Advisory Council (PFAC)


The purpose of the PFAC is to ensure the patient voice is incorporated into the everyday work of the ACO to help improve the quality of treatment experience for patients within MGB’s Medicaid ACO. The information from this council can help care teams and providers better understand and identify the needs of the ACO population.

  • The PFAC consists of MGB ACO Enrollees and family members of MGB ACO Enrollees.
  • The committee oversight and facilitation is governed by the Population Health Management (PHM) team responsible for Medicaid ACO activities.

Responsibilities of PFAC members

  • Provide input and advice on member experience survey results and other appropriate data and assessments.
  • Advise on the cultural appropriateness and member centeredness of necessary member or provider targeted services. 
    Includes: programs and trainings; marketing materials and campaigns; and partnerships.
  • Identify and Advocate for preventive care practices.

The committee meets quarterly and is typically held on a Thursday evening from 5-6pm via Zoom.

Please send questions or nominated members (and their contact information) to

Medical policy updates

Ten (10) medical policies were reviewed and passed by the Mass General Brigham Health Plan’s Medical Policy Committee. These policies are now posted to The table below is a summary.

For more information or to download our medical policies, go to and select the policy under the medical policy listings.

Medical Policies

Policy Title


Products Affected

Effective Date

Gender Affirming Procedures


March 2024: Annual Review. Clarified documentation requirements and removed requirement for separate letter of medical necessity from surgeon. Made other minor clarifying edits.  All products


Prostatic Urethral Lift

March 2024. Annual Review. 

All products


Neuromodulation for Overactive Bladder and Fecal Incontinence

March 2024: Annual Review.

All products


Preimplantation Genetic Testing

March 2024: Annual Review. 

All products


Radiofrequency Ablation to Treat Uterine Fibroids

March 2024: Annual Review.

All products


 Transurethral Waterjet Ablation for BHP

March 2024: Annual Review.

All products



March 2024: Annual Review. Changed requirement for no PSMA-negative lesions to no dominant PSMA-negative lesions on PSMA PET/CT scan. Medicare Advantage coverage added to table, and Medicare variation language added. 

  All products



March 2024: Annual Review.

 All products



March 2024: Annual Review.

 All products


IV Ketamine for Treatment-Resistant Depression

March 2024: Ad hoc update. Expanded coverage to include MGB ACO.

 All products



Drug code and code updates

View code updates for March 2024 here

New codes summary

View the January new codes summary here

Formulary updates

View the formulary updates here.