Medicare Advantage, Interqual update, and provider enrollment changes in September 2023

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In this issue:

• Medicare Advantage annual election period
• Interqual update
• Join our quality program committee to help improve the quality and effectiveness of our care
• Continuity of care-Mass General Brigham ACO
• Provider enrollment changes
• Mass General Brigham Health Plan’s Drug fee schedules to be updated
• Medical policy updates
• Formulary updates
• Code updates
• Drug code updates

Medicare Advantage annual election period

Hours changing

Join our quality program committee to help improve the quality and effectiveness of our care

Mass General Brigham Health Plan is seeking provider membership (including all MD specialties, NPs, and PAs) for its Quality Program Committee (QPC) to share expertise on topics that will ensure the quality and effectiveness of the care delivered to its members. Committee members have the opportunity to weigh in on a variety of health plan topics including:

• Network adequacy;
• Utilization Management and Medical Necessity Procedures;
• Member experience and satisfaction;
• Identifying and addressing potential health care disparities and inequities.

The QPC meets virtually on the third Wednesday every other month for 90 minutes. 

The meeting dates for the rest of 2023 are:

• Wednesday, October 18^th 7:30 a.m.-9:00 a.m.
• Wednesday, December 20^th 7:30-9:00 a.m.

If you are interested in joining the QPC, please contact Elaine Alden at Ealden@allwayshealth.org indicating your interest and we will reach out with information on the next steps regarding your participation.  Some providers may qualify to earn $300 per meeting.  Please feel free to contact us with any questions regarding your eligibility for this and/or any other questions that you may have about the Committee.

We appreciate the opportunity to collaborate with our provider network and thank you for the care you provide our members.

Continuity of care-Mass General Brigham ACO

Our continuity of care (CoC) period through 8/31/23 for the Mass General Brigham ACO, has now ended.

As a reminder, in the event of active ongoing services with an OON provider, after 8/31/23, 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 8/31/23), 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.

Here's what providers should know:

• Please ensure prior authorizations (PA) are submitted with all required documentation for all services that require PA. For more info, click here 
• Members will need prior authorization to see specialists out of network. See our provider directory for more information.
• Prior authorizations should be submitted via our provider portal 

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

Provider enrollment changes

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.

To keep accurate network provider information, Mass General Brigham Health Plan must be promptly notified in writing of relevant changes pertaining to a provider’s practice. The primary way to notify Mass General Brigham Health Plan of enrollment changes is through the Provider Enrollment Portal within the Mass General Brigham Health Plan Provider Portal https://provider.massgeneralbrighamhealthplan.org/Authentication/LogIn?ReturnUrl=%2F.

The Provider Enrollment Portal gives you easy access to submit requests such as the following:

• Enroll a new provider into your group
• Terminate an existing provider from your group
• Open and close your panels
• Submit demographic changes
• Generate a complete HCAS form

The Provider Enrollment Portal gives you real-time status information on your enrollment request as well as sends you an email notification when your request has been completed.

Providers can also submit provider enrollment changes via the following tools:

• Provider directory information landing page: Update directory | Mass General Brigham Health Plan
• Standardized Information Change Form http://www.masscollaborative.org/Provider_Information_Change_Form.pdf or with a signed document on the provider’s stationery. Completed forms should be emailed to HealthPlanPEC@mgb.org. Verbal requests and/or those submitted by third-parties or billing agents not on record as authorized to act on a provider’s behalf cannot be accepted.

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 HealthPlanProvidersService@mgb.org

A message for OT/PT/ST providers in the ACO network

Reminder: Prior Authorization (PA) is required for therapy services Please visit PA requirements page for more information:  Authorization guidelines | Mass General Brigham Health Plan

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 October 1, 2023. 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.

Medical policy updates

Four 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.

In addition, as of August 2023, Mass General Brigham Health Plan customized InterQual criteria and published new guidelines. The following criteria was customized and created:

1. Reduction Mammoplasty, Male (MassHealth) (Custom) – MGB

This customization was done to distinguish the criteria after adopting recent MassHealth updated Medical Necessity Guidelines.

Also, Mass General Brigham Health Plan customized InterQual criteria and published a new guideline.

1. CP: Imaging. The guidelines are called Imaging, Knee (Custom) - MGB

To access this criteria, providers should log in to Mass General Brigham Health Plan’s provider website at MassGeneralBrighamHealthPlan.org and click the InterQual® Criteria Lookup link under the Resources Menu.

Code updates

The following service(s) are covered with prior authorization required for Commercial/ASO and Medicare Advantage Plans:

The following service(s) are covered with prior authorization required for Commercial/ASO and Medicare Advantage Plans; Not reimbursable for MGB ACO Plans:

The following service(s) are covered with no prior authorization required for Medicare Advantage Plans:

The following service(s) are covered when prior authorized for MGB ACO Plans:

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 11/01/2023

The following changes are being made to the listed medications:

Updates for MassHealth Members

The following changes are being made to the listed medications to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List):

Effective ASAP

Effective 10/01/2023

Effective 11/01/2023