Commercial COVID-19 FAQ for providers

Read our COVID-19 payment policy.

In accordance with MA Chapter 260 of the Acts of 2020, we have removed copayments, deductibles, or coinsurance for medically necessary COVID-19 testing and treatment. This applies to inpatient and outpatient services at in- or out-of-network providers, including urgent care centers, emergency departments, hospitals, and other facilities. 

Please note that employers offering self-insured plans may have different cost sharing for these services. 

In addition, Mass General Brigham Health Plan aligns with the Centers for Medicare and Medicaid Services (CMS) guidance for coverage and payment for the evaluation, testing, and treatment for COVID-19 for Medicare Advantage members.

Members can log into the Member portal or call the customer service number on the back of their card for information about their plan benefits.

Commercial testing coverage (updated 5/9/2023)

Mass General Brigham Health Plan continues to follow current CDC and state public health department guidelines for testing coverage. Our members are covered without cost sharing for COVID-19 testing, when it is medically necessary and ordered by a PCP or treating provider. FDA-approved testing is also covered for commercial and Medicaid members when a person:

• Has been identified as a close contact by a public health entity for a known or suspected exposure to COVID-19.
• Works in an industry with increased exposure to the virus like health care, restaurant, hospitality, and retail industries.

Testing is not covered for third party administrative reasons — including but not limited to pre-employment or return to work, public health, return to school, and travel screenings.

For information about COVID testing and treatment coverage for MassHealth members, please visit our Medicaid FAQ.

• Massachusetts testing information

• Interactive map of Massachusetts testing sites

• Current list of FDA-approved COVID-19 tests

Diagnosis Codes for Evaluation for suspected Covid-19

• Z11.52: Encounter for Screening for Covid-19.
• Z20.822: Contact with and suspected exposure to Covid-19.
  
  

Diagnosis Codes for Treatment of Covid-19

• U07.1: COVID-19
• J12.82: Pneumonia due to coronavirus disease 2019
• M35.89 billed with B94.8/U09.9:
  
  • M35.89: Other specified systemic involvement of connective tissue
  • B94.8: Sequelae of other specified infectious and parasitic diseases (for dates of service through 9/30/2021)
  • U09.9: Post COVID-19 condition, unspecified (for dates of service from 10/1/2021 and forward)

 

If Multisystem Inflammatory Syndrome (MIS) develops as a result of a previous COVID-19 infection, assign codes M35.81 billed with B94.8/U09.9

• M35.81: Multisystem Inflammatory Syndrome
• B94.8: Sequelae of other specified infectious and parasitic diseases. (for dates of service through 9/30/2021)
• U09.9: Post COVID-19 condition, unspecified (for dates of service from 10/1/2021 and forward)

Mass General Brigham Health Plan follows ICD-10-CM Official Guidelines for Coding and Reporting and guidance from the Massachusetts Division of Insurance.

Please reference our comprehensive COVID-19 payment policy for the specimen collection and lab codes that are covered when medically necessary and ordered by a provider. 

To help prevent the spread of the coronavirus and support our provider partners during the public health emergency, we have expanded the scope of allowed telemedicine services and provider specialties.

In addition, to ensure continued access to care, we have removed cost sharing (copayments, deductibles, or coinsurance) for medically necessary COVID-19 telemedicine visits. As of January 1, 2021, cost sharing has resumed for non-COVID-19-related telemedicine visits with PCPs, specialists, and additional providers, such as urgent and routine care, and outpatient behavioral health services.

You can find complete information about billing for telemedicine in our COVID-19 payment policy.

We have expanded access to telemedicine services during the COVID-19 epidemic. 

For more information, please refer to our COVID-19 public health emergency telemedicine policy.

If a preventive visit has been rendered and billed via telehealth, Mass General Brigham Health Plan does not reimburse separately for a follow-up preventive visit in your office. Vaccinations and vaccine administration are separately reimbursable.

Please reference our COVID-19 payment policy for medications covered under the medical benefit.

For oral medications covered under the retail pharmacy benefit, please refer to the member's pharmacy benefit manager. 

As specific medications are developed to treat COVID-19, Mass General Brigham Health Plan follows Federal and/or State guidance for how it would be made available and for any applicable cost sharing requirements. There are currently some medications being utilized that are on our existing formulary without a prior authorization. Non-formulary prescriptions can be reviewed within 24 hours in cases of exigent circumstances. Please note COVID-19 on the request.

Mass General Brigham Health Plan is committed to ensuring timely access to critical health care services for COVID-19 for our members. During the COVID-19 public health emergency, we will cover immunizations for members age 3+ at a retail pharmacy, in addition to a provider’s office. As always, we encourage members to consult their primary care provider or pediatrician regarding childhood immunizations.

Please note employers that are self-insured may not offer prescription drug coverage through Mass General Brigham Health Plan. Members should check the details of their coverage by contacting their employer, visiting the member portal, or using the Mass General Brigham Health Plan member app.

If you have an immediate need to credential or enroll a provider, please indicate that on your request. In addition, please indicate if this is a permanent or temporary placement at your practice.

Prior to submitting any request to enroll or credential a medical provider, please check your rosters via the Mass General Brigham Health Plan Provider portal to validate current provider enrollments to your group billing NPI.  

Providers who have already been credentialed by Mass General Brigham Health Plan will not require any additional credentialing to provide services at a new location, however, they will need to be enrolled. To enroll a new provider to your group billing NPI:

• The fastest way to link an already credentialed provider to your practice is via the Mass General Brigham Health Plan Provider Portal.
• If you are not able to submit your enrollment via the Portal, please submit your HCAS form, which is available on the HCAS resource page, to healthplanPEC@mgb.org

Behavioral health providers should refer to the information on the Optum Provider portal.

There are no additional credentialing or enrollment submissions required for a medical provider that is enrolled in the Mass General Brigham Health Plan network to provide telemedicine services. Please refer to our public health emergency telemedicine policy for details.

Behavioral health providers should refer to the information on the Optum Provider portal.

Mass General Brigham Health Plan is adhering to standard turnaround times and prompt pay standards for all claims processing.  Standard claim editing applies and some claims may pend for manual review.  Manually reviewed claims are also subject to standard turnaround times.

Mass General Brigham Health Plan is paying in accordance with DOI guidelines during the public health emergency. Providers are not permitted to balance bill members for any costs above the DOI-mandated rates. This applies to fully insured and most self-insured commercial plans.

Click here to find instructions on submitting out-of-network claims to Mass General Brigham Health Plan.  

Yes, Mass General Brigham Health Plan reimburses approved facilities for the provision of Acute Hospital Care at Home services when medically necessary and provided by a CMS approved hospital.

Read our payment policy and provider FAQ for more information.