Provider payment guidelines

Reimbursement for out-of-network urgent care centers

Beginning on July 3, 2024, and ending on October 1, 2024, Mass General Brigham Health Plan will reimburse out-of-network urgent care centers in Massachusetts as requested below. This is in support of the recent directive from the Massachusetts Executive Office of Health and Human Services (EOHHS) and Assistant Secretary for MassHealth. Mass General Brigham Health Plan will reimburse urgent care centers in eastern Massachusetts* as follows:

• For Commercial members receiving services provided in urgent care centers with providers with whom Mass General Brigham Health Plan has a contract, but who do not participate in a member’s health plan, Mass General Brigham Health Plan will provide reimbursement for medically necessary urgent care services at the contracted rate for delivered services. Out-of-network providers are not allowed to balance bill members during this time.
  
  
• For Commercial members receiving services provided in urgent care centers with providers with whom Mass General Brigham Health Plan does not have any contract, Mass General Brigham Health Plan will reimburse medically necessary urgent care services at a rate equal to 135% percent of the rate paid by Medicare for medically necessary urgent care services. Out-of-network providers are not allowed to balance bill members during this time. 
  
  
• The MassHealth Program will reimburse at 100 percent of Medicaid.

Non-contracted providers in Massachusetts should submit claims directly to Mass General Brigham Health Plan (Payer ID: 04293). Please review our payment options and claims resource page before submitting claims using one of the following methods:

• Call Provider Service at 855-444-4647
• Mail paper claims to PO Box #323, Glen Burnie, MD 21060
• Submit a claim through the Provider Portal at MassGeneralBrighamHealthPlan.org
• Submit an electronic EDI claim to Payer ID 04293

For questions about reimbursement, please email HealthPlanProvRelations@mgb.org or visit the Provider Portal at Provider.MassGeneralBrighamHealthPlan.org.

*Commercial is limited to these counties: Essex, Middlesex, Suffolk, Norfolk, Bristol, Plymouth, Barnstable, Dukes, and Nantucket