Member resources & forms

When you buy safety helmets for toddlers, children, and adults, Mass General Brigham Health Plan will reimburse 50% of the purchase price of one new helmet, per member, per calendar year up to a $15.00 reimbursement.

Bike Helmet Reimbursement Form (PDF)

Breastfeeding support classes are also available free of charge at many primary care sites and hospitals. These classes are a support group for pregnant women, and they provide information about the benefits of breastfeeding, along with helpful tips, resources, and ways to manage common breastfeeding challenges.

Speak to the provider caring for you during your pregnancy, or the facility where you plan to deliver, about enrolling. If they do not offer a breastfeeding support program, Mass General Brigham Health Plan will reimburse you for the full cost of these classes. A Breastfeeding Support Form must be submitted to obtain the reimbursement.
Breastfeeding Support Form (PDF)

Childbirth education classes, plus parenting and infant CPR classes, are available to you and your partner or support person free of charge at many primary care sites and hospitals.

Speak to the provider caring for you during your pregnancy or the facility where you plan to deliver about enrolling. If they do not offer a childbirth education program, Mass General Brigham Health Plan will reimburse you for the cost of these classes up to $130 per pregnancy. You can combine multiple classes up to the $130 limit per pregnancy. A Childbirth Education Form must be submitted to obtain the reimbursement.
Childbirth Education Reimbursement Form (PDF)

Members newly enrolled through a small employer group who began an active course of treatment for a serious illness prior to enrolling in an Easy Tier Hospital Network plan may be eligible to continue treatment at the lowest member cost sharing tier (Tier 1). Click here to determine if you are eligible.

If eligible, the Continuity of Care at Cancer and Pediatric Facilities Notification Form (PDF) must be submitted prior to the start of treatment in the tiered network plan.

The fastest way to submit a reimbursement request for your fitness benefit is on the member portal, Member.MassGeneralBrighamHealthPlan.org. You can also download the form below and follow the instructions to submit your reimbursement request. The fitness benefit varies by plan. Please check Member.MassGeneralBrighamHealthPlan.org for details about your plan.

Fitness Benefit Coverage Form and Instructions (PDF)
 

Qualifying fitness facilities, programs/subscriptions or activities

The list includes, but is not limited to the following:

Please note: Aerobic exercise studios (Pilates, yoga, Zumba, etc.) and virtual fitness subscriptions are also included in this benefit.

Non-eligible facilities, programs or activities include, but are not limited to, country clubs and social clubs, spas, and 1 on 1 sessions. DVDs, equipment, and YouTube subscriptions are not covered.

Use this form to authorize Mass General Brigham Health Plan to release your Protected Health Information (PHI) to a designated recipient.

Authorization to Release Protected Health Information (PDF)

Use the Member Reimbursement Claim form to file an eligible behavioral health reimbursement. See form for details and instructions.

Member Behavioral Health Reimbursement Claim Form

Use the Member Reimbursement Claim form to file an eligible medical reimbursement. See form for details and instructions.

Member Medical Reimbursement Claim Form

Use this form to request your member record from Mass General Brigham Health Plan.

Member Record Request Form (PDF)

Use the Prescription Drug Reimbursement Form to file an eligible prescription drug claim reimbursement. See form for instructions.

Prescription Drug Reimbursement Form (PDF)

You have the right to choose one or more persons to act on your behalf with respect to the protected health information that pertains to you. If you would like to exercise this right, please complete and return this form to us.

For Commercial members

Authorize a Personal Representative: English | Español

For MassHealth/Mass General Brigham ACO members only

Authorize a Personal Representative: English | Español

Travel Benefit Reimbursement Form

This form can be used by members whose plans include a travel benefit from their employer. The travel benefit helps cover certain costs for members who need to travel in order to obtain services covered under their plan when state law does not allow a provider to administer such coverage in the state that the member resides.

See form for details on eligibility and instructions for reimbursement.

Travel Benefit Reimbursement Form (PDF)

The fastest way to submit a reimbursement request for your weight loss benefit is on the Member portal or our Member app. You can also download the form below and follow the instructions to submit your reimbursement request. The weight loss benefit varies by plan. Please check Member.MassGeneralBrighamHealthPlan.org for details about your plan.

Weight Loss Program Benefit Form and Instructions (PDF)
 
Qualifying weight-loss programs

• Weight Watchers (WW)
• Jenny Craig
• Noom- Effective for 1/1/2022

 
Please note: The weight loss program benefit does not cover food, nutritional supplements, or enrollment/registration fees.

Please log in to Member.MassGeneralBrighamHealthPlan.org for details about the information described below, or call the Customer Service number on the back of your Mass General Brigham Health Plan member ID card with any questions.
 

• Member rights and responsibilities
  • Your basic rights and responsibilities as a member.
• Availability of Member Handbook and Provider Directory
  • A summary of information included in your Member Handbook and details on how to use the Provider Directory.
• Notice of Privacy Practices
  • Our policy for protecting your health information.
• Post-mastectomy benefits
  • What you’re entitled to if you have a mastectomy.
• Appeal and grievance process
  • How to appeal a denial or submit a formal complaint.
• Preventive care guidelines for children
  • When your child should have preventive care and what’s covered.
• Preventive care guidelines for adults
  • When you should have preventive care and what’s covered.
• Incentives statement
  • Mass General Brigham Health Plan does not specifically reward providers or any organization reviewing our coverage decisions.
• Utilization management
  • How to learn more about coverage requests, approvals, and denials.
• Do You Have a Health Care Proxy?
  • How to choose a representative to speak for you in case you can’t make your own medical decisions.
• Care management and disease management services
  • A list of care management programs offered by your plan.