Pharmacy Benefit Manager Changing to Optum Rx on January 1, 2024

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In this issue:

• Pharmacy benefit manager changing to Optum Rx
• Rate adjustment for specialty services delivered via telehealth beginning January 1, 2024
• Complete Access Exclusive Provider Organization (EPO)
• MassHealth reimbursement for behavioral health crisis management 
• Appeal resolutions update from 30 to 60 calendar days
• FDA Announcement: Correct Dosage and Administration of Moderna COVID-19 Vaccine for Individuals 6 Months Through 11 Years of Age 
• DME overage requests

• MGB ACO: Oral Enteral Formulas

• Reminder of provider portal update
• Prior authorization requests
• Win a $100 gift card - Confirm your directory information and next available appointments
• Credentialing information for Urgent Care Center applications 
• Medical policy updates
• Medicare provider notification
• Drug code and code updates
• Formulary updates

Pharmacy benefit manager changing to Optum Rx

Beginning January 1, 2024, Mass General Brigham Health Plan will work with Optum Rx as our new pharmacy benefit manager (PBM). As health care changes at a rapid pace, Mass General Brigham Health Plan continues to innovate and build on our total cost of care model. To create lasting value for our clients and members we serve now and, in the future, we are changing our pharmacy vendor to Optum Rx. Making pharmacy care more affordable, accessible, supportive, and personal for our members is a shared goal with Optum Rx.

Provider trainings will be offered for Specialty Fusion, a system that integrates medical and pharmacy benefits into a single platform, so you can streamline your process while gaining full visibility to specialty trends. Registration information for the trainings will be included in the December newsletter. Two sessions will be offered; both sessions will cover the same content. Please mark your calendars for:

• Tuesday, December 12, 2023 - 10:00 AM EST to 11:00 AM EST Register here
• Thursday, December 14, 2023 - 4:00 PM EST to 5:00 PM EST Register here

For frequently asked questions (FAQs) about Optum Rx and Specialty Fusions, please visit our dedicated provider resource page. 

Rate adjustment for specialty services delivered via telehealth beginning January 1, 2024

At the start 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 recommendations and regulatory guidance.

On January 1, 2024, we will return 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, which will continue to be reimbursed at 100% of in-person rates. 

As we revert back to pre-pandemic operations and policies, we make these changes in accordance with state law (Chapter 260) and related guidance. There will be no changes to the scope of services that are allowed via telemedicine, at this time. We will continue to communicate with you as more information becomes available.

Complete Access Exclusive Provider Organization (EPO)

We are constantly expanding our plan offerings to meet the healthcare needs of our customers and your patients. To support this goal, Mass General Brigham Health Plan will introduce our Complete Access Exclusive Provider Organization (EPO) plan in 2024. For additional information and FAQs, please visit  Complete Access EPO for providers

MassHealth reimbursement for behavioral health crisis management 

Mass General Brigham Health Plan will comply with MassHealth guidance to ensure hospitals are reimbursed for ongoing team-based behavioral health crisis management after the initial behavioral health crisis evaluation. Additionally, Mass General Brigham Health Plan will reimburse hospitals for Recovery Support Navigator services and the Initiation of Medication for the treatment of Opioid Use Disorders in the Emergency Department.

This will apply to:

• MassHealth members, for dates of service 10/01/2023 and forward, per EOHHS guidance.

For billing information applicable to Mass Health members for dates of service 01/01/23-09/30/23, please refer to our provider payment guideline:  CrisisInterventionEDBoarding.pdf (allwayshealthpartners.org)

Appeal resolutions update from 30 to 60 calendar days

To align with industry standards and meet the expectations of our provider community, Mass General Brigham Health Plan will be increasing the timeframe of appeal resolutions from 30 calendar days to 60 calendar days.

FDA Announcement - Correct Dosage and Administration of Moderna COVID-19 Vaccine for Individuals 6 Months Through 11 Years of Age 

The FDA has found that some healthcare providers may not recognize that the single dose vial of Moderna COVID-19 Vaccine (2023-2024 Formula) contains more than the necessary 0.25 mL of the vaccine for use in individuals 6 months through 11 years.  

Please follow the below guidance when administrating the vaccine to ensure the correct dosage is used for individuals six months through eleven years: 

• Correct dose is 0.25 mL/25 mcg 
• Ensure the correct volume of the vaccine (0.25 mL) is withdrawn from the vial and administered to the recipient 
• Discard vial and excess volume after extracting a single dose (there may be significant excess volume left in the vial) 
• Never combine partial doses from multiple vials to make one dose for a patient 

Please be assured that the FDA has not identified any safety risks associated with the administration of the higher dose in patients 6 months through 11 years. No serious adverse events have been reported related to a dosing error for the vaccine. 

For additional information, we encourage you to refer to the FDA Announcement, the updated Moderna COVID-19 Vaccine (2023-2024 Formula) Healthcare Provider Fact Sheet (fda.gov), and Moderna COVID-19 Vaccine At A Glance: Updated 2023-2024 Formula (cdc.gov) 

DME overage requests

For any DME overage requests, a prior authorization needs to be submitted with the following information in the “Remarks” Section: 

• “The following is for an overage request for (appropriate codes and quantity) and requires Medical Necessity Review (with reason for request).” 

Supporting clinical documentation needs to be submitted at the time of request to complete the review process.

MGB ACO: Oral Enteral Formulas 

Attention Providers:  When billing for oral enteral formulas for MGB ACO members, you must submit a paper claim that includes the enteral formula product name, product description, and quantity  as well as a copy of the applicable invoice. Please mail paper claim and invoice to:  

Mass General Brigham Health Plan
P.O. Box 323
Glen Burnie, MD 21060

For more information related to claim submissions please refer to our Mass General Brigham Health Plan ACO Provider Manual.

Provider portal and prior authorization requests update

Effective 11/1/23, Fax number will be a mandatory field on the provider portal.  This upgrade is being put in place to help facilitate requests for additional information when needed.

Please ensure that all necessary clinical information is included at the time the prior authorization request is submitted.  This is to ensure timely processing of your requests.

Win a $100 gift card - Confirm your directory info and next available appointments

Please take a few minutes to complete both of the following brief forms by the end of November and you'll be automatically entered into our drawing to win a $100 gift card. 

1. Provider Directory Accuracy: Let us know if your information is accurate by completing this form.  
2. Future Appointment Access: Let us know about your next available appointments by completing this form.
   
   

Credentialing information for Urgent Care Center applications 

The following credentialing information is required when submitting an Application for Urgent Care Centers:

Urgent Care details below:

• CLIA
• W9
• Copies of State License(s) (If Applicable)
• Medicaid Certificate/Letter
• Medicare Certificates/Letter
  • • • Certificate of Accreditation
        -Accreditation of Association for Ambulatory Health Care (AAAHC)
        -Urgent Care Association (UCA)
        -The Joint Commission (TJC)
      • Copies of Malpractice/Liability Insurance Policy Face Sheets
      • Detailed List/Catalog of services provided
      • Federally Required Disclosure
      • If no accreditation, please include current site-visit documentation approved by the DPH
      • Mass Health PIDSL and Participation of Evidence (if ACO Provider)

Please note that Urgent Care Centers are recredentialed every two (2) years.

Medical policy updates

Six 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.

2024 Medicare provider notification

View the Medicare Provider Notification for November 2023 here.

New codes for Medicare Advantage

View the coverage summary for October 2023 new codes here. 

Drug code and code updates

View code updates for November 2023 here. 

Formulary and NCCN update

View the formulary updates for November 2023 here.