May 2024 - Mental Health Awareness Month, Tufts Medicine leaving ACO

Loneliness epidemic: How to help kids that feel isolated

Have you heard about the loneliness epidemic? The U.S. Department of Health and Human Services has called attention to the public health crisis of loneliness, isolation, and lack of connection in the United States. That’s why we had a conversation with Eugene (Gene) Beresin, MD, MA, and Khadijah Booth Watkins, MD, MPH, from The Clay Center for Young Healthy Minds at Mass General Hospital. Dr. Beresin is also the author of Child and Adolescent Psychiatry and the Media, Music (part of an Arts for Health series), and most recently, Ways to Help Your Lonely Teen. 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:

• Tufts Medicine leaving ACO on July 1
• Important information regarding Steward Health Care
• ACO Spotlight: Mental Health Awareness Month - BH resources and trainings for PCPs
• Coming soon: Submit new claims through the provider portal
• Improving call wait times
• Help us keep directory information up to date
• Tips for submitting a PCP change in the provider portal
• Confirmation of requested authorizations
• Annual updates to physician and outpatient fee schedules
• Medical policy updates
• Medicare provider notification
• Drug code and code updates
• New codes summary
• Formulary updates

Tufts Medicine leaving ACO network on July 1

Through our participation in the MassHealth Accountable Care Organization (ACO) program, Mass General Brigham Health Plan collaborates with a wide range of providers and community partners to offer a comprehensive network that meets our members’ healthcare needs. Starting July 1, 2024, Tufts Medicine affiliates and specialists will no longer be part of the Mass General Brigham ACO provider network. 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: Mental Health Awareness Month - BH resources and trainings for PCPs

Primary care providers often serve as the first point of contact for individuals seeking medical assistance. Coordination of care ensures that mental health concerns, lifestyle factors, and other behavioral aspects are integrated into a holistic healthcare plan, leading to more comprehensive and effective treatment. 

During Mental Health Awareness Month, Consider the following resources and training materials for primary care providers, as well as information on annual mental health examinations for patients.

Resources

• Explore our dedicated Behavioral Health Resources for PCPs page for convenient access to screening tools and valuable behavioral health resources. 

Trainings

• Optum Health Education is offering a fantastic opportunity to earn 3 CME/NCPD credits through their engaging Behavioral Health Identification, Treatment, and Referral in Primary Care - A 3-Part On-demand Learning Series. Register for free and discover more training options available at Optum Health Education.

• Medical management of depression, anxiety, and sleep
• Caring for people with substance use disorder in primary care

Annual mental health exams

Per MA DOI Bulletin 2024-02, Mass General Brigham Health Plan covers 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.

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’).
 

Coming soon: Submit new claims through the provider portal

(Updated 5/29) Coming soon, 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.

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.

Confirmation of requested authorizations

Network providers obtain confirmation of received authorization requests and UM decision-making from our online Provider portal, Provider.MassGeneralBrighamHealthPlan.org, including the authorization identification number, authorization decision, number of days/visits, and the duration approved or denied. Authorization reports specific to a member, individual authorization, or an aggregate of all requests made by the servicing provider are available through Provider.MassGeneralBrighamHealthPlan.org. 

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 May 2024 here. 

New codes summary

View the April new codes summary here. 

Formulary updates

View the formulary updates here.