Provider resource center

Mass General Brigham Health Plan adopts, endorses and implements these evidence-based guidelines from national sources, professional organizations, or developed by regional collaborative groups. Guidelines serve as a means of establishing standards among medical and behavioral health providers to improve health outcomes. They are not intended to replace clinical judgment.

ADHD
Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

Anxiety
Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders

Asthma
Asthma Management and Prevention
Asthma Management Guidelines

COPD/Emphysema
COPD Management Guidelines

Depression
Adult Guidelines - Major Depressive Disorder
Children and Adolescent Guidelines - Major Depressive Disorders

Diabetes
American Diabetes Association Guidelines

Heart Failure
Management of Heart Failure

High Blood Pressure
Guideline for the Management of High Blood Pressure in Adults
Management of High Blood Pressure

HIV/AIDS
HIV/AIDS Treatment Information Service Guidelines

Osteoporosis
Guidelines for Postmenopausal Osteoporosis

Perinatal care guidelines
Perinatal Care Guidelines - Massachusetts Health Quality Partners

Preventive care guidelines
Adult Preventive Care Guidelines - Massachusetts Health Quality Partners
Pediatric Preventive Care Guidelines - Massachusetts Health Quality Partners
US Preventive Task Force (USPTF) Recommendations

Substance Use Disorder/Alcohol Use Disorder
Guidelines for the Treatment of Opioid Use Disorder
Guidelines on Alcohol Withdrawal Management

Optum Resources for Mental Health/Behavioral Health
Clinical Practice Guidelines

Visit the drug alert page to find a complete list of medication recalls and safety information.

Submit claims for Mass General Brigham Health Plan members

Authorization request form for non-contracted and PHCS providers

Authorizations request form for Optum providers 

The federal No Surprises Act of 2021 received rulemaking restricts certain out-of-pocket costs to commercial consumers resulting from surprise billing and balance billing. This rule goes in effect for plan, policy, or contract years starting on or after January 1, 2022, for group health plans, health insurance issuers and Federal Employees Health Benefits (FEHB) program carriers and serves to:
 

• Ban balance billing for emergency services, air ambulance, and certain professional services provided by an out-of-network provider at an in-network facility. Cost sharing for these services must be determined on an in-network basis.
• Requires that patient cost sharing (copayments, co-insurance, or deductibles) for the services outlined above cannot be higher than if such services were provided by an in-network provider. Any cost sharing obligation must be based on median in-network provider rates.
• Prohibits balance billing for qualifying items or services provided by an out-of-network provider at an in-network facility unless a patient provides consent via the process required by CMS. You can reference CMS information here. Providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill the patient more than in-network cost-sharing rates. 

The forms and information below are provided in accordance with the federal No Surprises Act of 2021.
 
Open Negotiation Process
Non-participating providers who render services in an emergency room, an air ambulance, or for certain non-participating providers (for example, an anesthesiologist or radiologist) that provide non-emergency care in a participating facility will receive a Qualified Payment Amount (QPA) when the claim pays the first time.
 
If a non-participating provider rejects the QPA, they can engage in a 30-business-day open negotiation period with our designee, Clear Health Strategies, to agree on the appropriate rate for applicable items or services. You can find more information from Clear Health Strategies here.
 
As a reference for the open negotiation process with Clear Health Strategies, you can review the CMS documentation here.
 
Independent Dispute Resolution
If the Open Negotiation Process fails, either party can elect the Independent Dispute Resolution (IDR) process during the 4-business-day period beginning on the 31^st business day after the start of the open negotiation period. You can learn more about initiating the IDR process, view a sample Notice of IDR Initiation, and access the necessary IDR initiation form here.
 
Both parties must agree on the Independent Dispute Resolution entity. Failure to agree will result in an entity chosen by CMS (Centers for Medicare and Medicaid). Upon selection of the Independent Review entity, both parties will submit offers for payment as well as supporting documentation. The selected Independent Review Entity will issue a binding determination on the payment which will be considered final.

In the case of extenuating circumstances, either party may request an extension of the IDR time period by filling out this form and submitting it to CMS.

Use these guides to help you test and setup electronic claims-related transactions with Mass General Brigham Health Plan.

270/271 Eligibility Benefit Inquiry & Response
276/277 Claim Status Request & Response
278 Heath Care Services Review – Request for Review and Response
834 Benefit Enrollment and Maintenance
835 Electronic Remittance Advice (ERA)
837 Institutional Billing
837 Professional Billing

Medicaid Member Language Needs and Language Services Report

Unconscious Bias in Medicine
Sponsor: Stanford University School of Medicine
Number of credits: 1 credit
Fee: Free
Learn more

Reflecting on Health Disparities and Moving Towards Anti-Racism in Medicine
Sponsor: MMS
Number of credits: 1 credit
Fee: Free
Learn more

Think Cultural Health
Sponsor: HHS.gov
Number of credits: varies by program
Fee: Free
Learn more 

Mass General Brigham ACO Primary Care Sub-Capitation Resource Guide