Dual Eligible Special Needs Plans (D-SNPs)

Administrative simplification (e.g., only billing MGBHP for services, rather than Medicare and Medicaid separately), improved coordination, enhanced efficiency through integrated care management platform, and potential for higher reimbursement compared to fee-for-service.

Providers interested in enrolling in MGBHP’s SCO and One Care network should submit requests via HealthPlanPEC@mgb.org. Credentialing is required for directory-listed providers; enrollment is required for all. Additionally, providers must maintain current licensure, malpractice insurance, and update CAQH profiles every 90 days and notify MGBHP of roster changes and terminations at least 30 days in advance.

Both plans integrate Medicare and MassHealth benefits, plus supplemental supports. Covered services include inpatient/outpatient care, behavioral health, dental, vision, DME, home health, transportation, personal care, and more.

Member eligibility can be checked through the Provider Portal at Provider.MGBHP.org.

To opt-out of the D-SNP program, please email HealthPlanDSNPProvider@mgb.org.

Providers interested in enrolling in MGBHP’s SCO and One Care network should submit requests via HealthPlanPEC@mgb.org. Credentialing is required for directory-listed providers; enrollment is required for all. Additionally, providers must maintain current licensure, malpractice insurance, and update CAQH profiles every 90 days and notify MGBHP of roster changes and terminations at least 30 days in advance. 

Yes, providers can follow the normal request for enrollment via the Enrollment and Credentialing team at HealthPlanPEC@mgb.org. 

You can confirm your participation by searching the SCO Provider Directory: SCO Provider Directory or the One Care Directory: One Care Provider Directory. You may also call 855-444-4647.

Treat enrollees with fairness, respect, and without discrimination. Provide interpreter services for Limited English Proficiency (LEP) enrollees. Maintain confidentiality and comply with HIPAA. Discuss advanced directives and documents in medical records. Providers must not balance bill dual-eligible enrollees.

Claims can be submitted electronically, by paper, or via the Provider Portal: Mass General Brigham Health Plan Provider Portal. For additional information regarding paper claims submission, visit the Claims information page. 

Review for claims/appeals must be submitted in writing, within 90 days of the Explanation of Payment (EOP) along with any relevant information and documentation to support the request. When submitting a request for claim review or provider appeal, please use the Request for Claim Review Form and submit it via the Provider Portal. Additional information on appeal submission requirements is available via the Provider Manual at MGBHP.org.  

No, we’ll have one combined EOP for all lines of business.

Yes. An annual Model of Care (MOC) training is required. Training is available via webinars, online modules, and seminars. Providers must attest to completion for credit. 

Providers can utilize the following points of contact to assist with support or questions regarding benefit and provider guidelines.

• Provider Services: 855-444-4647 HealthPlanDSNPProvider@mgb.org
• Pharmacy: OptumRx: 844-368-8732 
• Behavioral Health: Optum Behavioral Health: 844-451-3520
• Dental: DentaQuest
• Transportation: Coordinated Transportation Solution
• Vision: EyeMed
• Meals (SCO only): Community Servings
• Dual Eligible Special Needs Plans

For more information, please reference the SCO/One Care Provider Manual SCO One Care Provider Manual or contact Provider Relations at HealthPlanDSNPProvider@mgb.org. 

Yes, providers are expected to participate in system education and practice engagement. Providers will have the opportunity to sign up for training or access trainings via the Provider resource center page. 

Providers are notified of training and educational sessions via the following communication channels: provider newsletters, Provider Portal, blog, monthly operations meetings, targeted email blasts, webinars, and training sessions.

Enrollees are required to select an in-network primary care provider upon enrollment into MGBHP’s SCO or One Care plans.

Referrals for specialty care are not required. Prior authorization may be required depending on the type of service being rendered and is always required for out-of-network services (except in urgent/emergent situations). You can verify authorization guidelines via the Prior authorizations and referrals page. 

When referrals or authorizations are required, providers may use the Mass General Brigham Health Plan Provider Portal. Out-of-network providers must submit their requests by fax to 617-586-1700.

Enrollees and providers can file grievances or appeals regarding care, access, or payment. Appeals must be submitted within 65 days; expedited processes are available for urgent cases. Call Member Services at 888-816-6000 or email HealthPlanDSNPMAAppealsGrievances@mgb.org.

Adhere to federal and state regulations. Report suspected fraud to the Compliance Office or hotline at 844-556-2925. Maintain accurate records for seven years. Providers must self-disclose overpayments within 60 days.

• Provider manual
• Monthly provider newsletter
• Plan websites