Home
Provider Administrative newsletter
MassHealth eligibility redeterminations, calls to customer service, and provider resources in May 2023

MassHealth eligibility redeterminations, calls to customer service, and provider resources in May 2023

May 01, 2023

Featured story: When irritable bowel syndrome (IBS) flares, here's how to put out the flames

IBS symptoms can include nausea, gas, bloating, diarrhea, constipation, migraines, and general discomfort. Severe IBS symptoms might include debilitating and sudden pain that limits the ability to work or socialize or chronic pain that feels like a constant ache. These symptoms can have a ripple effect on sleep, mood, and exercise capacity, which can, in turn, worsen the effects of IBS.

In this issue:

MassHealth eligibility redeterminations
Calls to customer service
Continuity of Care Process for MGB ACO
Crisis Intervention – ED Boarding provider payment
Annual Updates to Physician and Outpatient Fee Schedules
Medical policy updates
Code updates
Drug code updates
Formulary updates

MassHealth eligibility redeterminations

On April 1, 2023, MassHealth began eligibility redetermination for all MassHealth members. This process has been on pause since the COVID-19 public health emergency began in March 2020. Below are links to resources created by MassHealth to assist members and providers through this process.

MassHealth eligibility redeterminations home page
MassHealth Renewal Help Guide - A guide to helping members with renewals.
Helping MassHealth members with their renewals - Information for front-line staff about helping with redetermination.
Flyers, posters, and member-facing materials for MassHealth redeterminations - Materials to help spread the word about redeterminations.
MassHealthRenew.org - Help for members to renew their coverage.

Calls to customer service

We are temporarily experiencing unusually high call volume in our customer service center. For the fastest service, please use our secure provider portal to check claims, verify eligibility, submit/check a PA request, and more.

Mass General Brigham Health Plan Contacts


Provider Portal: Claims status, eligibility, EOP	Mass General Brigham Health Plan Provider Portal
Claims issues, benefits	Provider Service 855-444-4647 HealthPlanproviderservice@mgb.org
Portal IT support	HealthPlanprweb@mgb.org
Provider enrollment and credentialing, directory issues	HealthPlanpec@mgb.org
Medical policies, payment policies, provider manual, provider directory, drug lookup, forms	Providers \| Mass General Brigham Health Plan
Audit denial inquiries	audit@allwayshealth.org

Mass General Brigham Health Plan provider resources

MGBHP conducted virtual trainings for operational staff on the utilization authorization process which are available on the Provider Education Landing Page
Provider Portal - Mass General Brigham Health Plan Provider Portal
-Member management tool, Provider enrollment, Eligibility verification etc.
- - Provider Education Landing Page - Provider education | Mass General Brigham Health Plan
    -Access webinars, factsheets, and other tools that make it easy to do business with us.
    - Claims Landing Page - Claims information (massgeneralbrighamhealthplan.org)
      -Access Payer ID numbers and addresses for submitting medical and behavioral health claims.

Public Website Provider Tab - Providers | Mass General Brigham Health
-We aim to deliver an optimal provider experience with easy-to-use tools that support you, your patients, and your healthcare practice

Continuity of Care Process for MGB ACO

Per EOHHS , currently a 90 day Continuity of Care period is occurring from 4/1/23-6/30/23 for a new MGB ACO member with a previously approved scheduled procedure/service (for a covered service) by the previous health plan, with an in network (INN) or out of network (OON) provider, which will continue or occur post MGBHP MGB ACO effective date. Those authorizations which have been transitioned to us from MassHealth have an end date of 6/30/2023.

As a reminder, in the event of active ongoing services with an OON provider, after 6/30/23, the provider must submit the request for continued service via our Mass General Brigham Health Plan Provider Portal. If the current authorization with the in network provider has expired (past 6/30/23), and the member still requires the service, then the provider will need to submit a request for prior authorization. These are considered a new request for services and not Continuity of Care as the previously approved services auth has ended and will be reviewed by our Utilization Management Team. Any historical and current supporting clinical documentation should be included with the prior authorization request.

For more information and tools regarding the MGB ACO please visit: Mass General Brigham ACO | Mass General Brigham Health Plan

For questions, contact our Provider Service Center at 855-444-4647 or via email at healthplanproviderservice@mgb.org

Crisis Intervention – ED Boarding provider payment

Mass General Brigham Health Plan will comply 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 will apply to:

Commercial members, for dates of service 11/01/2022 and forward per MA DOI Bulletin 2022-08
MassHealth members, for dates of service 01/03/2023 and forward per EOHHS guidance issued by the Office of Behavioral Health per MCE bulletin 93

Mass General Brigham Health Plan reimburses medical facilities for the provision of medically necessary crisis intervention services to treat and stabilize to Mass General Brigham Health Plan members awaiting an inpatient acute psychiatric placement in a facility emergency department (ED) or observation setting. Click here for provider payment guidelines.

You can also visit mass.gov for the Expedited Psychiatric Inpatient Admissions (EPIA) Policy or view this presentation.

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 physician, ambulance, drug, DME, laboratory, radiology and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2023.

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, 2023.
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, 2023. Rate updates to existing CPT and HCPCS codes will occur within 30 days of receipt of notification of rate change from MassHealth.

Medical policy updates

Eight 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 massgeneralbrighamhealthplan.org/providers/medical-policies and select the policy under the medical policy listings.

Medical Policies
Policy Title	Summary	Products Affected	Effective Date
Phototherapy and Photochemotherapy for Dermatologic Conditions	May 2023: Off-cycle Update. Removed visit limitation for lasers to treat vitiligo.	All lines of business	5/1/2023
Zynteglo (New Policy)	May 2023: Effective date. An autologous hematopoietic stem cell-based gene therapy indicated for the treatment of adult and pediatric patients with transfusion dependent β-thalassemia with a non-β0/β0 or β0/β0 genotype.	All lines of business	5/1/2023
Skysona (New Policy)	May 2023: Effective date. An autologous hematopoietic stem cell (HSC)-based gene therapy indicated for the treatment of patients with confirmed early, active cerebral adrenoleukodystrophy (CALD).	All lines of business	5/1/2023
Absorbent Products	May 2023: Annual Update. Added medicare advantage to table 1. References Updated.	All lines of business	5/1/2023
Out Of Network Providers	May 2023: Annual Update. No changes.	All lines of business	5/1/2023
Experimental and Investigational	May 2023: Annual Update. No changes.	All lines of business	5/1/2023
Durable Medical Equipment	May 2023: Annual Review. Medicare Advantage added to table on page 1. Medicare Variation language added. References updated.	All lines of business	5/1/2023
Dental Treatment Setting	May 2023: Off-cycle review. Non-material changes made for clarity purposes. Added statement under table on page 1. Added statement regarding MassHealth members to exclusion #2.	All lines of business	5/1/2023

Code Updates

The following service(s) previously required prior authorization will be covered with no prior authorization for Medicare Advantage lines of business:

Code	Description	Effective Date
K1025	Nonpneumatic sequential compression garment, full arm	04/01/2023

The following service(s) previously not covered will be covered with no prior authorization for Medicare Advantage lines of business:

Code	Description	Effective Date
K1006	Suction pump, home model, portable or stationary, electric, any type, for use with external urine management system	04/01/2023

The following service(s) previously required prior authorization will be covered with no prior authorization for Commercial/ASO and ACO lines of business:

Code	Description	Effective Date
67334	Strabismus surgery by posterior fixation suture technique, with or without muscle recession (List separately in addition to code for primary procedure)	4/1/2023

The following service(s) will be covered with no prior authorization for all lines of business:

Code	Description	Effective Date
No code	Vueway for use with MRI to detect and visualize lesions with abnormal vascularity in the central nervous system (brain, spine, and associated tissues) and the body (head and neck, thorax, abdomen, pelvis, and musculoskeletal system).	4/1/2023

The following service(s) will be covered with no prior authorization for Commercial lines of business:

Code	Description
No code	Natural Cycles Birth Control App

The following service(s) will be covered with no prior authorization for ACO lines of business:

Code	Description	Effective Date
G0310	Immunization counseling by a physician or other qualified health care professional when the vaccine(s) is not administered on the same date of service, 5-15 minutes time (This code is used for Medicaid billing purposes).	2/1/2023
G0311	Immunization counseling by a physician or other qualified health care professional when the vaccine(s) is not administered on the same date of service, 16-30 minutes time (This code is used for Medicaid billing purposes).	2/1/2023
G0312	Immunization counseling by a physician or other qualified health care professional when the vaccine(s) is not administered on the same date of service for ages under 21, 5-15 minutes time (This code is used for Medicaid billing purposes).	2/1/2023
G0313	Immunization counseling by a physician or other qualified health care professional when the vaccine(s) is not administered on the same date of service for ages under 21, 16-30 minutes time (This code is used for Medicaid billing purposes)	2/1/2023
G0314	Immunization counseling by a physician or other qualified health care professional for COVID-19, ages under 21, 16-30 minutes time (This code is used for the Medicaid Early and Periodic Screening, Diagnostic, and Treatment Benefit [EPSDT])	2/1/2023
G0315	Immunization counseling by a physician or other qualified health care professional for COVID-19, ages under 21, 5-15 minutes time (This code is used for the Medicaid Early and Periodic Screening, Diagnostic, and Treatment Benefit [EPSDT]).	2/1/2023
99446	Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review.	4/1/2023
99447	Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a verbal and written report to the patient's treating/requesting physicia1n or other qualified health care professional; 11-20 minutes of medical consultative discussion and review.	4/1/2023
99448	Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 21-30 minutes of medical consultative discussion and review.	4/1/2023
99449	Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 31 minutes or more of medical consultative discussion and review.	4/1/2023
99451	Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a written report to the patient's treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time.	4/1/2023
99452	Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes.	4/1/2023

Drug Code Updates

The following drug(s) are now covered under the medical benefit with prior authorization for ACO and Commercial/ASO lines of business:

Code	Description	Brand Name	Effective Date
C9149	Injection, teplizumab-mzwv, 5 mcg	Tzield	4/1/2023 *6/5/2023 for MassHealth*
No Specific Code	Injection, mosunetuzumab-axgb, for intravenous use	Lunsumio	4/1/2023
No Specific Code	Suspension, recal microbiota, live - jslm, for rectal use	Sunlenca	4/1/2023
No Specific Code	Injection, lenacapavir, for subcutaneous use	Rebyota	4/1/2023

The following drug(s) will be covered with no prior authorization for ACO and Commercial/ASO lines of business:

Code	Description	Brand Name	Effective Date
No Specific Code	Injection, VASOPRESSIN, for intravenous use	Vasopressin/NaCl	4/1/2023

The following drug(s) will be covered with no prior authorization for ACO lines of business:

Code	Description	Brand Name	Effective Date
J9305	Injection, pemetrexed, NOS, 10 mg	Alimta	5/1/2023
No Specific Code	Oral (dexmedetomidine) sublingual film, for sublingual or buccal use (*J8499 should be used to report this drug until such time CMS assigns a permanent HCPCS code)*	Igalmi	5/1/2023
J9294 J9296 J9297	Injection, pemetrexed (Hospira), not therapeutically equivalent to J9305, 10 mg Injection, pemetrexed (Accord), not therapeutically equivalent to J9305, 10 mg Injection, pemetrexed (Sandoz), not therapeutically equivalent to J9305, 10 mg	Pemetrexed	5/1/2023
J2777	Injection, faricimab-svoa, 0.1 mg	Vabysmo	5/1/2023
No Specific Code	Injection, VASOPRESSIN, for intravenous use	Vasopressin/NaCl	4/1/2023

The following drug(s) are now covered under the medical benefit with prior authorization for ACO lines of business:

Code	Description	Brand Name	Effective Date
J9302	Injection, ofatumumab, 10 mg	Arzerra	5/1/2023
J9301	Injection, obinutuzumab, 10 mg	Gazvya	5/1/2023
J9274	Injection, tebentafusp-tebn, 1 mcg	Kimmtrak	5/1/2023
J9298	Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg	Opdualag	5/1/2023
J9359	Injection, loncastuximab tesirine-lpyl, 0.075 mg	Zynlonta	5/1/2023

The following drug(s) are now covered under the medical benefit with prior authorization for Medicare Advantage lines of business:

Code	Description	Brand Name	Effective Date
C9149	Injection, teplizumab-mzwv, 5 mcg	Tzield	4/1/2023
No Specific Code	Injection, mosunetuzumab-axgb, for intravenous use	Lunsumio	4/1/2023
No Specific Code	Suspension, recal microbiota, live - jslm, for rectal use	Rebyota	4/1/2023
No Specific Code	Injection, lenacapavir, for subcutaneous use	Sunlenca	4/1/2023
No Specific Code	Injection, VASOPRESSIN, for intravenous use	Vasopressin/NaCl	4/1/2023

Formulary Updates

DEFINITIONS

Formulary These drugs are included in Mass General Brigham’s covered drug list.

Non-Formulary These drugs are not included in Mass General Brigham’s formulary. The plan would only cover formulary alternatives. Providers can request Non-Formulary drugs as an exception, and the plan would require trial of all appropriate formulary alternatives prior to approving coverage of a Non-Formulary drug. If a Non-Formulary drug is approved, the member’s cost sharing would be the highest tier.

Preferred These drugs are on Mass General Brigham’s formulary and offer a lower cost to members.

Non-Preferred These drugs are on Mass General Brigham’s formulary but offer a higher cost to members.

Excluded Mass General Brigham does not cover these drugs. Members will receive a denial for all Excluded drug requests.

Updates for Commercial Members

Effective 07/01/2023

The plan will update morphine milligram equivalency (MME) calculations consistent with the recently updated Centers for Disease Control and Prevention (CDC) opioid prescribing guideline.

MME-Based Opioid Utilization Management (UM) Quantity Limit (QL) Updates:
Hydromorphone oral soln 5 mg/5 mL (1 mg/mL)	The quantity limit will be updated to 480 mL per month with a maximum daily dose of 16 mL.
Hydromorphone tab 4 mg	The quantity limit will be updated to 120 tabs per month with a maximum daily dose 4 tablets.
Methadone 10 mg	The quantity limit will be updated to 30 tablets per month with a maximum daily dose 1 tablets.
Methadone 10 mg/mL Intensol soln	The quantity limit will be updated to 45 mL per month with a maximum daily dose 1.5 mL.
Methadone 10 mg/	The quantity limit will be updated to 225 mL per month with a maximum daily dose 7.5 mL.

Updates for MassHealth Members