Mass General Brigham
ACO Provider Manual
Mass General Brigham Health Plan—Provider Manual 1 – Member Information
1-1 2024-05-01
Section 1: Member information
Mass General Brigham Health Plan
1-2
Member Enrollment 1-2
Primary Care Assignments 1-2
Enrollment Activities 1-2
Mass General Brigham ACO
Customer Service 1-3
Mass General Brigham ACO Mass General
Brigham Health Plan Member Onboarding 1-3
Member Eligibility and Identification 1-3
Copayments 1-4
Mass General Brigham Health Plan
Identification (ID) Cards 1-4
Patient Relations 1-4
Member Rights and Responsibilities 1-4
Assistance with Interpretation/Communication 1-5
Privacy Rights 1-6
Treatment of Minors (Privacy) 1-6
Accessing Emergency Services 1-6
Optum Partnership 1-7
Advance Directives 1-8
Communicating with Patients 1-8
Escalating Protocols 1-8
Terminating a Patient from Your Practice 1-9
Notification to Member 1-9
Mass General Brigham Health Plan—Provider Manual 1 – Member Information
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Section 1: Member information
Mass General Brigham ACO
Mass General Brigham Health Plan and Mass
General Brigham ACO offers care and coverage
through MassHealth, and Mass General Brigham
Health Plan.
As both provider and insurer, Mass General Brigham
ACO and Mass General Brigham Health Plan work
together in providing integrated medical and
behavioral health care.
As an ACO program member, Mass General Brigham
ACO members must select a Mass General Brigham
Health Plan Primary Care Provider (PCP).
Mass General Brigham ACO member benefits vary
based on their plan design. A member may be
enrolled on any of the following
MassHealth plans:
• Standard
• CommonHealth
• Family Assistance
• CarePlus
Mass General Brigham ACO members may be
eligible for any service covered directly by
MassHealth, such as routine dental care. Please
refer to the Member Handbook and the Covered
Services list for more information.
Member Enrollment
The Mass General Brigham Health Plan's Provider
Portal is designed to offer network providers around
the clock access to enrollment and eligibility
information via timely updates and helpful reports.
Member enrollment and eligibility changes are
provided daily to PCPs through the provider portal to
enhance patient care, facilitate PCP outreach efforts
and enable updates to their own practice
management systems.
Primary Care Assignments
Mass General Brigham ACO members must select a
primary care site and a Primary Care Provider (PCP)
who participates in the Mass General Brigham ACO
network.
PCPs should make best efforts to reach out to newly
assigned members to provide an overview of their
practice, assess any medical needs and, when
applicable, schedule an initial appointment.
Enrollment Activities
Mass General Brigham ACO members who do not
select a PCP upon enrollment are allowed a grace
period to make a selection and otherwise, are
assigned to an ACO participating PCP using criteria
such as location, gender and other family member’s
PCP’s. Members can change PCPs at any time by
logging into their Member Portal account or
contacting Customer Service.
When applicable, primary care network providers can
also process updates to a Mass General Brigham ACO
member’s PCP assignment within the same practice,
including satellite locations, through the Mass General
Brigham Health Plan’s provider portal.
The Provider Portal provides important enrollment
transaction updates for Primary Care offices, including
retroactive enrollment changes. Available reports
include:
• A Provider Roster report listing all currently enrolled
clinicians
• A Member Roster report listing all actively enrolled
Mass General Brigham ACO members assigned to
the site
• Transaction reports listing the latest enrollment
transactions including:
–
Patients no longer enrolled with Mass General
Brigham ACO
–
Patients who have elected to get their primary
care elsewhere
–
New Mass General Brigham ACO members
who have chosen the practice as their primary
care site
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–
Existing Mass General Brigham ACO members
who have transferred from another Mass
General Brigham Health Plan primary care site
–
PCP updates processed by Mass General
Brigham Health Plan at the member’s request
•
When applicable, the portal’s Redetermination
reports also provide advanced information to
primary care practices on Mass General Brigham ACO
members whose MassHealth eligibility is being
redetermined
To ensure proper reimbursement, providers are
strongly encouraged to review available enrollment
activity data regularly and notify Mass General
Brigham Health Plan’s Provider Service (855-444-
4647) of any discrepancies.
Mass General Brigham ACO Customer Service
Mass General Brigham Health Plan’s highly skilled
Customer Service Professionals are
available to assist with questions on eligibility,
benefits and policies or procedures.
Customer Service Professionals can also assist with
updates to a member’s address and/or phone
information identified by providers. Attestation to the
patient’s consent is required for processing these
demographic updates.
Note that all PCP information updates must be
requested through the Provider Portal.
Customer Service Contact Information:
Providers
Phone: 855-444-4647
Mon.–Fri., 8:00 am – 5:00 pm
and closed 12:00 pm-12:45 pm
Mass General Brigham ACO Members
Phone: 800-462-5449 TTY:711
Email:
HealthPlanCustomerServiceMembers@mgb.org
Mon.–Fri. 8:00 am – 6:00 pm
Thursday, 8:00 am – 8:00 pm
MassHealth Customer Service
Contact Information
Phone: 800-841-2900 TTY: 800-497-4648
Mass General Brigham ACO
Member Onboarding
Once enrolled, Mass General Brigham ACO members
have access to a variety of materials detailing benefit
and other important information via the member
portal and public website. Available materials include
the MassHealth Covered Services List and Member
Handbook plus corresponding amendments. In
addition, the member portal provides medical and
pharmacy claims history, status on submitted
approval requests and other member information on
file with Mass General Brigham Health Plan.
Mass General Brigham ACO members are provided
with a Mass identification card and Welcome Guide
containing information about how to use their plan.
Member Eligibility and Identification
All members receive a Mass General Brigham ACO
member identification card that must be presented in
addition to the MassHealth card when accessing
services.
A Mass General Brigham ACO member ID card itself
does not guarantee that an individual is currently
enrolled with Mass General Brigham Health Plan,
however providers are responsible for verifying
eligibility at each visit and when applicable, daily via
the provider portal. This includes but is not limited to
while a patient is hospitalized. Eligibility information is
also available on the New England Healthcare
Exchange Network (NEHEN).
Mass General Brigham Health Plan will only reimburse
for covered services rendered to a patient eligible on
the date of service and when all prior-authorization
and payment requirements are met. Except in
emergencies, patient eligibility should be determined
prior to rendering services.
The provider portal is designed to offer providers
around the clock access to member information and
other administrative functions.
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Copayments
Mass General Brigham ACO members have no
office visit copayment. A pharmacy copayment may
apply depending on the selected medication, age,
or income.
Occasionally, a Mass General Brigham ACO member
may not be able to pay the applicable pharmacy
copayment at the time the prescription is filled.
Under these circumstances, members should notify
the pharmacist of their inability to afford the
copayment. Under federal law, and as contractually
required, the pharmacy must still dispense the
medication as prescribed. However, Mass General
Brigham Health Plan is not responsible for the
copayment due to the pharmacy. The patient remains
liable for any applicable copayment amounts and the
pharmacy may exercise its legal rights to collect the
amount due.
Mass General Brigham ACO Identification (ID) Cards
The Mass General Brigham ACO member ID card
provides important information for members and
providers as shown below.
Patient Relations
Member Rights and Responsibilities
Mass General Brigham ACO members are
entitled to specific rights, including accessing
and correcting medical records information, as
shown below.
Members must be allowed to freely apply these
rights without negatively affecting how they are
treated by providers and/or Mass General Brigham
Health Plan. In addition, providers must treat Mass
General Brigham ACO members with fairness,
honesty, and respect, including refraining from any
biases based on race, color, national origin, age,
disability, sex, religion, sexual orientation, gender
identity, gender expression, ancestry, marital
status, veteran status, occupation, claims
experience, duration of coverage, pre- existing
condition, expected health status, or ability to pay
for services.
Member Rights Mass General Brigham ACO members
have the right to:
• Receive information about Mass General Brigham
Health Plan, our services, our providers and
practitioners, their covered benefits, and their rights
and responsibilities as a member of Mass General
Brigham Health Plan.
• Receive documents in alternative formats and/or
oral interpretation services free of charge for any
materials in any language.
• Have their questions and concerns answered
completely and courteously.
• Be treated with respect and with consideration for
their dignity.
• Have privacy during treatment and expect
confidentiality of all records and communications.
• Discuss and receive information regarding their
treatment options, regardless of cost or benefit
coverage, with their provider in a way which is
understood by them. Members may be responsible
for payment of services not included in the Covered
Services list for your coverage type.
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• Be included in all decisions about their healthcare,
including the right to refuse treatment and the right
to receive a second opinion on a medical procedure
at no cost to them.
• Access emergency care 24 hours a day, seven days
a week.
• Change their PCP.
• Access an easy process to voice their concerns
and expect follow-up by Mass General Brigham
Health Plan.
• File a grievance or appeal if they have had an
unsatisfactory experience with Mass General
Brigham Health Plan or with any of our contracted
providers, or if they disagree with certain decisions
made by Mass General Brigham Health Plan.
• Make recommendations regarding Mass General
Brigham Health Plan’ “Member Rights and
Responsibilities.”
• Create and apply an advance directive, such as a
will or a healthcare proxy, if they are over 18 years
of age.
• Be free from any form of restraint or seclusion
used as a means of coercion, discipline,
convenience, or retaliation.
• Freely apply their rights without negatively affecting
the way Mass General Brigham Health Plan and/or
their provider treats them.
• Ask for and receive a copy of their health record and
request that it be changed or corrected as explained
in the Notice of Privacy Practices in the Member
Handbook.
• Receive the Covered Services they are eligible for.
• Member Responsibilities
• Mass General Brigham ACO members have the
responsibility to:
• Choose a primary care provider (PCP), the provider
responsible for managing their care.
• Call their PCP when they need healthcare.
• Tell any healthcare provider that they are a Mass
General Brigham ACO member.
• Give complete and accurate health information that
Mass General Brigham Health Plan or their provider
need to provide care.
• Understand the role of their PCP in providing their
care and arranging other healthcare services that
they may need.
• To the degree possible, understand their health
problems and take part in making decisions about
their healthcare and in developing treatment goals
with their provider.
• Follow the plans and instructions agreed to by them
and their provider.
• Understand their benefits and know what is covered
and what is not covered.
• Call their PCP within 48 hours of any emergency or
out-of-network treatment. If they experienced a
behavioral health emergency, they should contact
their behavioral health provider if they have one.
• Notify Mass General Brigham Health Plan of any
changes in personal information such as address,
telephone, marriage, additions to the family,
eligibility of other health insurance coverage, etc.
• Understand that they may be responsible for
payment of services they receive that are not
included in the Covered Services.
Assistance with Interpretation
and Communication
When applicable, Mass General Brigham Health Plan
contracted practices must provide interpreter services
free of charge to limited English proficiency (LEP)
members, including but not limited to over the phone
communication. This requirement is in keeping with
Title VI of the Civil Rights Act of 1964 that requires
recipients of federal financial assistance to provide
translation or interpretation services as a means of
ensuring that their programs and activities normally
provided in English are accessible to LEP persons, and
thus do not discriminate on the basis of national
origin. The provision of translation or interpreter
services must comply with applicable state and
federal mandates and take into account relevant
guidance issued by the Department of Health and
Human Services Offices of Civil Rights Minority Health,
as well as the Massachusetts Office of Health Equity.
Mass General Brigham Health Plan contracted
providers must have the capacity to communicate
with members in languages other than English,
communicate with individuals with special health
care needs (including with those Who are deaf,
Mass General Brigham Health Plan—Provider Manual 1 – Member Information
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hard-of-hearing, or deaf blind), and make materials
and information available in alternative formats.
The following resources are available to assist
providers in meeting this obligation:
• The US Department of Health and Human Services
Office of Minority Health’s publication, “A Patient-
Centered Guide to
• Implementing Language Access Services in
Healthcare Organizations,” can be found at:
www.minorityhealth.hhs.gov. This website
also includes information on interpreter
services, regulations, and requirements.
• Additional information on Executive Order 13166,
“Improving Access to Services for Persons with
Limited English Proficiency,” and its applicability
to healthcare providers can be found at
www.lep.gov.
Privacy Rights
Mass General Brigham Health Plan believes strongly in
safeguarding the personal and health information of
our members and expects all providers to fully comply
with applicable state and federal regulations
regarding confidentiality of health information,
including but not limited to the privacy and security
regulations promulgated under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA).
It is important that privacy regulations do not impact
patient treatment or quality of care. Absent specific
authorization from the patient, HIPAA allows for the
exchange of information needed for treatment,
payment, and healthcare operations. Examples that
are applicable to the relationship between Mass
General Brigham Health Plan and providers include,
but are not limited to:
• Payment - The exchange of information needed
to ensure that appropriate payment is made for
services provided to members, including fulfilling
authorization requirements, rendering payment,
and conducting retrospective audits.
• Healthcare operations - The collection of
information for quality assessment and
improvement activities such as Healthcare
Effectiveness Data and Information Set (HEDIS)
audits, medical record reviews, the investigation
of grievances, quality of care issues, or suspected
fraud and abuse. The exchange of information
that enables the coordination of medical care for
Mass General Brigham Health Plan member by
our team of Care Managers or the provision of
information to our providers concerning their
patients’ utilization of medical services.
Mass General Brigham ACO members are
informed of their privacy rights, including how
Mass General Brigham Health Plan uses their
information, by distribution of our Notice of
Privacy Practices.
Treatment of Minors (Privacy)
State law allows minors, under certain circumstances,
to consent to medical treatment without parental
consent. In such situations, the minor would be able
to initiate an appeal or designate an appeal
representative with respect to that medical treatment
without parental consent. In such circumstances, the
minor needs to consent to the release of information
concerning that medical treatment, even to the
parent(s).
Providers are encouraged to seek legal counsel
with any questions about minors’ consent to
medical treatment and patient confidentiality
and privacy.
Providers with questions or concerns about
Mass General Brigham Health Plan’s privacy practices
can call the Compliance Hotline at 1-844-556-2925.
Accessing Emergency Services
Mass General Brigham ACO members are covered for
emergency care, even when traveling outside the
service area throughout the United States and its
territories. Coverage includes use of an ambulance
and post-stabilization care services related to an
emergency. Members can go to any emergency room;
the hospital does not have to be part of the Mass
General Brigham Health Plan provider network.
An emergency is a health condition a member
believes will put their health in serious danger if
immediate medical attention is not received.
Examples of emergencies are:
• Chest pain
• Poisoning
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• Trouble breathing
• Severe bleeding
• Convulsions
• Having thoughts of hurting yourself or others
If a member believes their health problem is an
emergency and needs immediate attention, the
member should be instructed to call 911 at once or go
to the nearest emergency room right away to be
examined and stabilized before being discharged or
transferred to another hospital.
If a member is experiencing a behavioral health
emergency, the member should call 911, go to
the nearest emergency room, or contact the
Community Behavioral Health Center (CBHC) in
their area.
A list of emergency rooms in all areas of the state
can be found in the Mass General Brigham Health
Plan Provider Directory.
Members should contact their PCP within 48 hours
of any emergency care. If applicable, the PCP will
arrange follow-up care. Members experiencing a
behavioral health emergency should be instructed
to contact their behavioral health provider if they
have one.
Members are covered for emergency care 24 hours
a day and seven days a week, even when traveling or
outside the service area.
Community Behavioral Health Centers (CBHCs) can
offer community-based behavioral health services
when a hospital emergency department visit may
not be required. Readily available services include
crisis assessment, interventions, and referrals to
appropriate services.
While some circumstances may necessitate a
behavioral health crisis evaluation in an emergency
department setting, there are many times when an
individual can best be served by having a crisis
evaluation conducted at the member’s home, CBHC,
or a community-based location, such as the PCP’s
office.
PCPs should consider contacting a local CBHC for
Mass General Brigham Health Plan Mass General
Brigham ACO members presenting with the
following:
• Complaints of feeling depressed or having suicidal
thoughts
• Deteriorating mental status brought on by recent
noncompliance with psychotropic medications or
reactions to changes in medical regime
• Inability to utilize usual coping strategies when in
crisis
CBHCs are available 24/7 and should respond within
60 minutes of being contacted. Additional information
about CBHCs is available from the Mass.gov website
at: Community Behavioral Health Centers | Mass.gov
For a listing of CBHCs in all areas of the state, patients
can refer to the Provider Directory.
Optum Partnership
Mass General Brigham Health Plan partners with
Optum in managing the delivery of behavioral health
services for all Mass General Brigham ACO members.
The following behavioral health areas of
responsibility are delegated to Optum:
• Claims processing and claims payment
• Provider contracting and credentialing
• Quality management and improvement
• Service authorization
• Utilization management/case management
Advance Directives
Mass General Brigham ACO members have the right
to execute advance directives such as healthcare
agents and healthcare proxies, living wills, and organ
donation cards to inform healthcare providers what
to do if they become unable to make decisions about
their care.
When applicable, providers should discuss with
patients their wishes for an advance directive as part
of office visits. The discussion should be documented
in the patient’s medical record and updated regularly,
including whether the patient chooses to execute an
advance directive. If a patient establishes a written
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advance directive, it is advised that a provider
maintain a copy of this in the patient’s medical
record. Additional information on advance directives
is available at www.caringinfo.org.
Communicating with Patients
Effective patient-provider communication is vital to
good health outcomes and patient satisfaction. Low
literacy rates can sometimes compromise a patient’s
understanding, despite the clinician’s efforts. Many
patients struggle with understanding; patients with
limited health literacy are more likely to be
hospitalized or more frequently use emergency
services. Limited English proficiency and/or a patient’s
medical and emotional health can also affect
communication between patients and medical
practice staff.
Patients should be educated at the first visit as to
what to expect from providers and their office staff.
Information such as missed appointments and other
practice policies, Patient Rights and Responsibilities,
turnaround for returning phone calls, and the process
for filling prescriptions must be covered early on to
ensure a mutual understanding of expectations. The
patient must receive a clear explanation (preferably in
writing) of what is acceptable and what is not
acceptable behavior for effective patient-provider
interactions. Provider office staff should also receive
adequate training for dealing with patients up to and
including:
• Respecting the Patient Bill of Rights
• Avoiding using the caregiver status as a threat to
the patient
• Incorrect assumptions about contributing factors to
patient behaviors
• Dismissive verbal or body language that can fuel
anger
• Adequate communication of acceptable and
unacceptable patient behavior • Depersonalizing
patient behavior
Escalating Protocols
Partnering with the patient in his or her care is key to
effective patient-provider relationships. It is
recommended that clinicians start by creating rapport
with the patient, asking for his or her goals in seeking
care and understanding the impact of the illness on
the patient’s life. Conveying empathy, verbally and
non- verbally, delivering the diagnosis in terms of his
or her original concerns, and educating the patient
are key to successfully completing an office visit.
When communicating with limited English proficiency
patients, using trained medical interpreters (versus a
minor, family member, or non-trained personnel) can
result in a more accurate diagnosis, greater patient
compliance, and in some cases, a bridge to address
patient-provider cultural gaps. Ideally this need is
determined at the time of registration so that an
interpreter can be involved early on and be scheduled
for all the patient’s appointments. Otherwise, an
interpreter should be called immediately when the
need is discovered.
There should be a brief discussion between the
interpreter and the clinician beforehand to clarify the
goals of the visit. When meeting with the patient,
clinicians should speak directly to the patient and not
to the interpreter. A trained medical interpreter
should use the first person, thus speaking as the
doctor and the patient. For effective interpretation,
sentences should be kept short and simple, avoiding
use of complicated medical terminology, and
repeating critical information such as medication
names and/or dosage as requested.
When dealing with patients, understanding factors
affecting their behavior can help greatly in developing
a plan to effectively manage them. It is sometimes
possible to predict patients who may become easily
agitated, irrational, or violent, depending on their
medical condition.
Rushing through a visit can be counter-productive.
Providers are encouraged to pay close attention to the
patient’s words, voice, or attitude to pick up anger
signs or levels that might express fear, anger, or
violence. Providers should directly address their
patient’s underlying feelings, making eye contact
always, and addresses the patient in a respectful
manner using their preferred title and name.
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Terminating a Patient from Your Practice
Mass General Brigham Health Plan (MGBHP)
recognizes the critical importance of a positive
therapeutic relationship and is committed to working
with provider practices in developing and maintaining
strong provider-patient relationships. However, we
recognize that at times the relationship may be
jeopardized by the actions of a member and that on
rare occasions, a provider may contemplate
terminating a member from the practice. A patient’s
behavior isn’t always indicative of being angry at their
health care providers. Validating a patient’s frustration
and concerns may go a long way in improving
therapeutic relationships. Termination from a practice
while a member is in an emergent or urgent care
situation, in the latter stages of pregnancy or is not
mentally competent, is rarely justifiable.
Medical office staff should be trained to maintain a
professional demeanor and when appropriate, leave
the room after conveying empathy with the patient’s
situation, giving him or her time to think about what is
happening.
Mass General Brigham Health Plan is committed to
collaborating closely with the provider and the
member. This includes but is not limited to:
• Facilitating access to behavioral health treatment
and community resources
• Participating in case conferences upon request
• Providing intensive care management
Providers are expected to make every effort to resolve
incompatible patient relationships and to proactively
notify Mass General Brigham Health Plan of
unresolved patient issues as they are identified by
emailing Provider Services at
The notification must include the patient’s name and
date of birth in addition to copies of documented
attempts made to address the patient’s behavior prior
to reaching the decision and any other supporting
documentation. Mass General Brigham Health Plan
staff will acknowledge receipt and the provider will be
contacted directly if additional information is needed
to review the request.
To avoid delays in the review of submitted requests,
please do not submit these to MassHealth directly.
MassHealth will not process practice-level
disenrollment requests submitted to them directly.
As part of our thorough review of these cases, MGBHP
may request additional and/or missing information,
including a copy of the practice’s patient rights and
responsibilities or code of conduct policy, when
applicable. If it is jointly determined that the issues
cannot be addressed to the satisfaction of all parties
and that the only alternative is terminating the patient
from the practice, the decision should not be
communicated to the member until after coordinating
with Mass General Brigham Health Plan. This will
ensure effective continuity of care and that these
decisions are made in an objective and fair manner.
Notification to Member
The provider is responsible for communicating, in
writing, first to Mass General Brigham Health Plan and
then to the member the reason for the decision and
the effective date of termination. Except in instances
of imminent danger, the member must be provided
with at least 30-days advance notice to transition their
care to another provider. At a minimum, the letter
should include:
• The reason for the decision
• The effective date of termination
• A summary of previous attempts made by the
provider’s practice to work with the patient prior
to reaching the decision
• The option to continue care for at least 30 days
while the patient makes other arrangements
• Process for the transfer of medical records
• Instructions to contact Mass General Brigham
Health Plan Customer Service for assistance
selecting a new provider, when applicable
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Section 2: Covered services
Overview 2-2
General Coverage Requirements 2-2
Covered Services 2-2
Long Term Care 2-2
Clinical Trials 2-4
Dental Care 2-4
Oral Surgery 2-5
Other Dental Care 2-6
Vision 2-6
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Section 2: Covered services
Overview
Covered Services
Mass General Brigham ACO members have benefit
coverage as outlined by their plan:
MassHealth Standard and CommonHealth, Family
Assistance, and CarePlus. For a complete list of ACO
covered services
It is important for providers to confirm a (covered by
Mass General Brigham Health Plan) member’s
eligibility and coverage upon arrival for an
appointment as coverage for certain services varies
by plan.
Some benefits have limits, and it is important to note
each plan’s definition of “benefit period.” and non-
ACO covered services (covered by MassHealth
directly), please refer to the Covered Services booklet.
The Covered Services booklet provides a table-
formatted summary of benefit coverage for each plan.
• Benefits with a contract or benefit period limit
apply a calendar year: January 1 through
December 31
• Some benefits have a rolling period (for example, a
routine eye exam may be covered once every 12
months or 24 months based on the patient’s age).
This would require that the next appointment be
booked 12 months/24 months and 1 day after the
current appointment.
General Coverage Requirements
To be covered by Mass General Brigham Health Plan,
all health care services and supplies must be:
• Provided by or arranged by the patient’s Mass
General Brigham ACO Mass primary care provider
(PCP) or Mass General Brigham ACO network
provider*
• Referred by the PCP when required (most specialty
care outside the Mass General Brigham Health Plan
network requires a referral)
• Prior authorized when required
• Medically necessary
• Covered health care services
• Provided to eligible patients enrolled in Mass
General Brigham ACO
*Exceptions: Mass General Brigham ACO members can access
family planning services from any MassHealth Provider. Mass
General Brigham ACO members can access emergency services
as note in Section 1, “Accessing Emergency Services”
Covered Services
Mass General Brigham ACO members have benefit
coverage as outlined by their plan: MassHealth
Standard and CommonHealth, Family Assistance,
and CarePlus.
It is important to note Mass General Brigham ACO
members have coverage for services through
MassHealth that are not covered by Mass General
Brigham Health Plan. For example, adult day services
for the disabled may be covered through MassHealth
but are not covered by Mass General Brigham Health
Plan. Members may confuse their “Fee for Service
Medicaid “or MassHealth coverage with their Mass
General Brigham ACO Mass coverage. Mass General
Brigham Health Plan’s Customer Service team is
available to further clarify coverage for members.
Mass General Brigham ACO members have some
variation in coverage based on their plan; the
following is a high-level outline of excluded services.
Long Term Care
Mass General Brigham Health Plan’s Long-Term Care
(LTC) coverage for MassHealth members allows 100
LTC days a contract year/benefit period. LTC coverage
depends on the member's MassHealth benefit plan as
follows:
• MassHealth Standard,
CommonHealth, Family
Assistance, and CarePlus: Mass General Brigham
Health Plan covers up to 100 days of a combination of
Nursing Facility, Chronic Disease and Rehabilitation
Hospital services In a Contract Year (January 1 –
December 31
st
).
• Depending on the facility type, a Status Change
for Members in a Nursing Facility or Chronic
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Disease and Rehabilitation Inpatient Hospital
form (commonly referred to as the SC1 Form) and
a MassHealth Payment of Nursing Facility Services
form (commonly referred to as the Screening
Form) may be required from the facility.
• Copies of the required forms must be provided to
Mass General Brigham Health Plan immediately
upon request. For Nursing Facility admissions
(which require the additional Screening form) the
requested copy must be received by Mass
General Brigham Health Plan no later than by the
100
th
day. Noncompliance will result in payments
being withheld and released only upon
confirmation from the MassHealth Enrollment
Center (MEC) that the form has been correctly
completed and accepted in their system.
Non-covered laboratory services include:
• Test performed for experimental or Clinical
Investigational purposes or that are themselves
experimental or clinically investigational
• Tests only for the purpose of civic, criminal,
• administrative, or social service agency
investigation, proceedings, or monitoring activities
• Test for residential monitoring purposes
• Tests performed to establish paternity
• Tests performed by an independent clinical
laboratory for services that the laboratory is not
certified by Centers for Medicare & Medicaid
Services (CMS) to perform
• Services provided by a provider not in the Mass
General Brigham ACO network unless prior
authorized
Overview of Excluded Medical Services for MassHealth Plans
Care Plus Plan
CommonHealth and
Standard Plans
Family Assistance Plan
Early and Periodic Screening,
Diagnosis,
and Treatment (EPSDT)
Services (members under age
21)
Excluded
Included
Excluded, however
Preventive Pediatric
Healthcare Screenings and
Diagnostic [PPHSD]
Services are covered.
Early Intensive Behavioral
Intervention (EIBI)
Excluded
Included
Included
Early Intervention
Excluded
Included
Included
Fluoride Varnish
Excluded
Included
Included
Non-Emergent
Transportation Out of
State (outside a 50-mile
radius of the MA border
Included
Included
Excluded
Mass General Brigham Health Plan—Provider Manual 2 – Covered Services
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• Except as otherwise noted or determined
Medically Necessary by EOHHS, the reasons, or
mammoplasty following mastectomy or as
required by law following services are not covered
under MassHealth and as such are not covered by
Mass General Brigham Health Plan
• Assisted reproduction including but not limited to
in-vitro fertilization and gamete intra-fallopian
tube (GIFT) procedures
• Cosmetic surgery, except as determined to be
medically necessary for correction or repair of
damage following an injury or illness, for other
medically necessity reasons, or mammoplasty
following mastectomy or as required by law
• Experimental treatment
• Non-covered laboratory services as specified in
130 CMR 401.411
• Out-of-country care (outside USA and territories)
including emergency care
• Personal comfort items including, but not limited
to, air conditioners, radios, telephones, and
televisions
Services and supplies not directed by Mass General
Brigham ACO Provider
These services do not need to be directed by a Mass
General Brigham Health Plan provider:
• Emergency services
• Family planning services provided by a MassHealth
provider
Clinical Trials
Mass General Brigham Health Plan does cover care
provided as part of a Qualified Clinical Trial for the
treatment of cancer or other life- threatening medical
condition to the extent the care would be covered if
not provided as part of a Qualified Clinical Trial.
Coverage is provided when services are provided by a
Mass General Brigham Health Plan network provider
or with prior authorization for a provider outside the
Mass General Brigham ACO network. Covered costs
exclude: the investigational item, device, or service;
items and services solely for data collection and
analysis; or for a service that is clearly inconsistent
with widely accepted and established standards of
care for a particular diagnosis. Costs and limitations
imposed are not greater than costs or limitations
when the services are provided outside of an
approved clinical trial.
The PCP (or treating provider in consultation with
the PCP) must obtain prior authorization for a
member’s participation in a Qualified Clinical Trial
or the member must provide medical and scientific
information that
demonstrates the member meets the conditions for
participation in the qualified clinical trial. The prior
authorization process must be followed.
Qualified clinical trials meet the following:
The clinical trial is intended to treat cancer or
other life-threatening medical condition in a
patient who has been so diagnosed.
The clinical trial has been peer reviewed and is
approved by one of the following:
• United States National Institutes of Health (NIH)
• Center for Disease Control and Prevention
• Agency for Health Care Research and Quality
Centers for Medicare and Medicaid Services
• The Department of Defense, Veterans Affairs, or
the Department of Energy
• A qualified non-governmental research entity
identified in NIH guidelines for grants, is a study
or trial under the United States Food and Drug
Administration approved investigational new drug
application, or it is a drug trial that is exempt from
investigational new drug application
requirements
• The facility and personnel conducting the clinical
trial are capable of doing so by virtue of their
experience and training and treat a sufficient
volume of patients to maintain that expertise
• With respect to Phase I clinical trials, the facility
shall be an academic medical center or an
affiliated facility, and the clinicians conducting the
trial shall have staff privileges at said academic
medical center
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• The patient meets the patient selection criteria
enunciated in the study protocol for participation
in the clinical trial
• The patient has provided informed consent for
participation in the clinical trial in a manner that is
consistent with current legal and ethical
standards
• The available clinical or pre-clinical data provide a
reasonable expectation that the patient’s
participation in the clinical trial will provide a
medical benefit that is commensurate with the
risks of participation in the clinical trial
• The clinical trial does not unjustifiably duplicate
existing studies
The clinical trial must have a therapeutic intent and
must, to some extent, assess the effect of the
intervention on the patient.
Dental Care
Mass General Brigham Health Plan has limited dental
benefits for its patients as outlined below.
EMERGENCY DENTAL CARE
Mass General Brigham Health Plan covers emergency
dental services only when there is a traumatic injury
to sound, natural, and permanent teeth caused by a
source external to the mouth and the emergency
dental services are provided in a hospital emergency
room or operating room within 72 hours following
the injury.
FLUORIDE VARNISH
Mass General Brigham ACO providers offering
fluoride varnish application are entitled to
reimbursement. Fluoride varnish is usually
deemed medically necessary beginning on or
around six months of age (first tooth eruption)
and may be medically necessary for members up
to adulthood (up to age 21).
Fluoride varnish is applied during a well-child visit to
prevent early childhood dental caries in children at
moderate to high risk as determined by the Caries
Assessment Tool (CAT). More information on this tool
is available from the American Academy of Pediatrics
website at www.aap.org.
Fluoride varnish is recommended no more frequently
than every 180 days from the first tooth eruption
(usually at six months) to the third birthday. It is
expected that this procedure will occur during a
pediatric preventive care visit and will be delivered
along with anticipatory guidance for oral health
and/or dental referral when necessary.
While this benefit is primarily intended for
children up to age three, reimbursement is
allowed for children up to adulthood (see above).
To be eligible for fluoride varnish
reimbursement, all of the following criteria must
be met:
• The individual rendering the service may be a
Physician, Nurse Practitioner, Physician Assistant,
Registered Nurse, Licensed Practical Nurse, or
Medical Assistant certified in the application of
fluoride varnish.
• The individual rendering the service must
complete the Oral Health Risk Assessment
Training or equivalent.
• The provider must meet all claim submission
requirements including use of valid procedure
codes.
• The member is under the age of 21.
• The service is medically necessary as determined
by a Caries Assessment Tool (CAT).
PCP sites that do not have providers or staff certified
in the application of fluoride varnish must direct
patients in need of fluoride varnish to Mass General
Brigham Health Plans’ Customer Service team for help
finding a certified provider.
Oral Surgery
Coverage for Mass General Brigham Health Plan Mass
General Brigham ACO members is limited to medically
necessary oral surgery, including the extraction of
wisdom teeth, performed in a Surgical Day Care (SDC)
or as an inpatient because of an underlying medical
condition. The coverage applies to the procedure,
facility, and all professional fees.
Mass General Brigham Health Plan—Provider Manual 2 – Covered Services
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Other Dental Care
For Mass General Brigham ACO members under age
21, and under special circumstances for adults,
routine dental care may be covered by MassHealth.
For more information on covered services, please
refer to MassHealth Covered Services List.
Orthodontics (braces) for teeth and dentures are not
covered by Mass General Brigham Health ACO
members but may be covered by MassHealth. Full and
partial dentures, and repairs to said dentures, are
covered for adults age 21 and over by MassHealth.
Vision
Mass General Brigham ACO Mass members have
coverage for a comprehensive eye exam; however,
the frequency of the eye exam may vary according to
the patient’s age; please check the plan materials.
All Mass General Brigham ACO members have
coverage for medically necessary ophthalmological
care, including vision training, under the specialty
care coverage.
All Mass General Brigham ACO members have
coverage for lenses that are medically necessary to
treat medical conditions such as keratoconus or
after cataract surgery. Other than this limited
coverage, eyewear (eyeglasses and contact lenses) is
not covered. Scleral lenses (bandage lenses) are
covered when medically necessary; prior
authorization is required.
Mass General Brigham ACO members have coverage
for routine vision exams:
• Once per 12-month period for patients under the
age of 21
• Once per 24-month period for patients age 21 and
older
• For all patients, when medically necessary
• Eyeglasses are covered through MassHealth for
MassHealth CarePlus, CommonHealth/Standard,
and Family Assistance members.
Mass General Brigham Health Plan—Provider Manual 3 –Provider Management
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Section 3: Provider management
Joining the Mass General Brigham
Health Plan Network 3-1
Board Certification Requirement 3-1
Primary Care Provider Group (PCPG) 3-1
Role of the Primary Care Provider 3-2
Role of the Specialty Provider 3-2
Credentialing 3-2
The Credentialing Committee 3-3
Practitioner Rights 3-3
Sanctioned Providers 3-4
Appeals Process 3-6
Reporting to Appropriate Authorities 3-6
Credentialing Requirements 3-7
The Credentialing Process 3-8
The Re-credentialing Process 3-8
Locum Tenens 3-8
Provider Enrollment 3-8
Provider Enrollment Changes 3-9
Panel Changes 3-10
MassHealth Provider Enrollment
Requirement 3-10
Behavioral Health Care Integration 3-11
Provider Rights and Responsibilities 3-11
Member Complaints and Grievances 3-12
Access and Availability Requirements 3-12
Cultural Competency 3-13
Wait Time Access Standards 3-13
Fraud, Waste and Abuse 3-13
Fraud Prevention 3-13
Reporting Health Care Fraud 3-14
False Claims Act 3-14
Waste Identification, Reimbursement
Validation and Recoveries 3-14
General Claims Audits 3-15
On-Site Audit 3-16
Off-Site Audit 3-16
Provider Appeals 3-16
Fraud, Abuse, and the Special
Investigations Unit 3-17
Preservation of Records and Data 3-18
Code of Ethics 3-18
Provider Marketing Activities 3-18
“Hold Harmless” Provision 3-18
Provider Notification and Training 3-19
Role of the Mass General Brigham Health Plan
Provider Network Account Executive 3-19
Network Account Executive 3-19
Mass General Brigham Health Plan—Provider Manual 3 –Provider Management
3-1 2024-05-01
Section 3: Provider Management
Joining the Mass General Brigham
Health Plan Network
Providers can join the Mass General Brigham Health
Plan ACO network by submitting the request in
writing to the Mass General Brigham Health Plan
Network Growth team.
Participation in the Mass General Brigham ACO
provider network requires the execution of a
provider agreement. This agreement contains the
provisions that govern the relationship between
Mass General Brigham Health Plan and the
provider.
A clinician or group will be considered a participating
provider only upon successful execution of a provider
agreement. The provider must notify Mass General
Brigham Health Plan of any changes to the
information submitted in the initial application
request to contract. Material omissions and/or
misstatements in the application request to contract
will deem the contract voidable.
The contract will be effective as of a date is
determined by Mass General Brigham Health Plan, and
the provider will be notified accordingly. Mass General
Brigham Health Plan will not reimburse for any
services provided prior to the effective date of the
contract.
When applicable, credentialing requirements
must be met before becoming a contracted
provider.
Some changes in a provider’s practice may require
reconsideration by Mass General Brigham Health Plan,
up to and including re-application for continued
participation as a network provider. These changes
include but are not limited to:
• Change in practice location to a different state
• Change in practice specialty
• Change in ownership
• Entering or exiting from a group practice
• Changes in hospital privileges
• Change in insurance coverage
• Disciplinary and/or corrective action by a licensing
or federal agency
• Material changes in the information submitted at
the time of contracting.
To initiate these changes, please send an email* to
*Please do not send Protected Health Information
(PHI) through unsecured email.
Board Certification Requirement
Board certification for PCPs and specialty physicians is
required to ensure that the percentage of board-
certified PCPs and specialty physicians participating in
the Mass General Brigham Health Plan network, at a
minimum, is approximately equivalent to the
community average for PCPs and specialty physicians.
Participating physicians are required to be either
board-certified or board- eligible and to be actively
pursuing board certification in order to participate in
the network.
During the initial credentialing process and then every
two years, Mass General Brigham Health Plan will
validate a participating physician’s board certification
status. If the participating physician is not board-
certified, he/she must provide written documentation
that they are board- eligible and are actively pursuing
board certification within the required time period as
defined by the American Board of Medical Specialties
(ABMS) or American Osteopathic Association (AOA).
Any provider that is not board-certified and not
appropriately board- eligible must receive approval to
be added to the Mass General Brigham Health Plan
ACO network.
Primary Care Provider Group (PCPG)
A primary care provider group (PCPG) is an entity
whose practice is in general/internal medicine,
pediatrics, family practice, or OB/GYN and who is
contracted with the Mass General Brigham Health
Plan ACO network to provide and coordinate
comprehensive healthcare services to all assigned
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3-2 2024-05-01
members. A PCPG may be a health center, hospital
ambulatory care clinic, or other physician practice and
can consist of one or more clinicians and/or locations.
Role of the Primary Care Provider
The primary care provider (PCP) provides or manages
first-contact, continuous, and comprehensive health
care services for a defined group of assigned patients
at his/her primary care site. The PCP is responsible for
providing, arranging for, and coordinating the
provision of covered services to his or her patients.
For optimal coordination of care, Mass General
Brigham Health Plan Mass General Brigham ACO PCPs
should only refer to specialists within the Mass
General Brigham Health Plan ACO network whenever
possible.
A PCP can be an individual physician, a registered
nurse practitioner, or a physician assistant eligible to
practice one of the following specialties:
• Family practice
• Internal medicine
• OB/GYN
• Pediatrics
Role of the Specialty Provider
A specialty provider is responsible for the provision
of covered specialty care services working in
collaboration with the member’s PCP.
Specialty providers should communicate their findings
in a timely manner to the PCP and when applicable,
other referring providers. A consultation is not
considered complete until the specialist’s provision of
a written report to be incorporated by the PCP’s office
into the patient’s medical record.
Credentialing
Mass General Brigham Health Plan has a full
credentialing delegation agreement with Andros
Technologies, Inc.
Credentialing is a process used to ensure that
providers who intend to participate and practice in a
Mass General Brigham Health Plan network meet a
level of quality compared to established standards.
Mass General Brigham Health Plan uses the National
Committee on Quality Assurance (NCQA) guidelines in
the credentialing process. Mass General Brigham
Health Plan continuously strives to expand the
capacity of its provider networks through the
credentialing process in order to have multilingual
practitioners available to members who are
responsive to linguistic, cultural, ethnic, and other
unique needs of minority groups or special
populations and who do not unlawfully discriminate
based upon state or federal laws and regulations. The
credentialing application collects information on a
practitioner’s languages spoken.
Mass General Brigham Health Plan expects that all
credentialed practitioners obtain the required
Continuing Education Units in their practice areas as
recommended by their applicable licensing board.
Unless based on access requirements where
exceptions are granted, all credentialed physicians
must be board-certified in their medical specialty or
be in the process of achieving initial certification in a
time frame relevant to guidelines established by their
respective medical specialty board. In some cases,
Mass General Brigham Health Plan retains the right to
contract and enroll providers who are not board
certified if there is a shortage of providers in that
specialty. Upon receipt of a physician’s new
certification status, the physician is required to notify
Mass General Brigham Health Plan of his or her new
certification status. Mass General Brigham Health Plan
monitors all non-board-certified physicians’ board
certification at least every two years or at the time of
the physician’s re-credentialing cycle.
At a minimum, all medical doctors (MDs), Doctors of
osteopathy (DOs), Doctors of Optometry (ODs),
Doctors of Chiropractic Medicine (DCs), doctors of
podiatric medicine (DPMs) and any independently
licensed and practicing practitioner must be
credentialed by Mass General Brigham Health Plan.
Doctors of Dental Medicine (DMDs) and Doctors of
dental surgery (DDSs) must be credentialed in order
to be participants in Mass General Brigham Health
Plan Mass General Brigham ACO network. Allied
professionals such as physical therapists (PTs),
occupational therapists (OTs), and speech and
Mass General Brigham Health Plan—Provider Manual 3 –Provider Management
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language therapists (SLTs) are also subject to
credentialing requirements at a group level. Nurse
practitioners (NPs) and physician assistants (PAs)
(acting in the role of a PCP), and certified nurse
midwives (CNMs) are also eligible for credentialing
and billing under their corresponding National
Provider Identifier (NPI) number.
A nurse practitioner or a physician assistant,
practicing within the scope of his or her license,
including all regulations requiring collaboration
with a physician, may choose to enroll as a PCP
subject to member assignments.
Re-credentialing occurs in a two-year cycle consistent
with the practitioner’s birth month and year.
Hospital-based physicians with specialties in
pathology, emergency room, anesthesiology, and
radiology (also known as HERAP providers) practicing
exclusively in a facility setting or facility-based
emergency room are not credentialed by Mass
General Brigham Health Plan. That list would also
include NPs (specialists), covering providers, locum
tenens, urgent care providers, and critical care
medicine specialists. However, they are reviewed and
privileged through their respective licensed
institutions, which includes review of their credentials.
Behavioral health practitioners are credentialed by
Mass General Brigham Health Plan’ behavioral
health benefits manager, Optum.
The Credentialing Committee
The Credentialing Committee is Mass General Brigham
Health Plan’ peer review body with responsibility for
oversight of the credentialing and recredentialing
functions. The committee meets monthly, or as
needed, to review other applications and includes
consultants actively practicing in some of the same
specialties as those practitioners credentialed by Mass
General Brigham Health Plan.
Mass General Brigham Health Plan’ Chief Medical
Officer, or designee, is responsible for oversight of the
credentialing program. Portions of the credentialing
process may be delegated. However, Mass General
Brigham Health Plan retains the right to approve new
clinicians and to terminate or suspend existing
clinicians.
At each meeting, the Credentialing Committee
makes one of the following credentialing
decisions about inclusion in or exclusion from
Mass General Brigham Health Plan’ provider
networks:
• Approve
• Conditionally approve (with a corrective action
plan and follow-up)
• Table for more information and further review
• Decline/deny
Practitioner Rights
Mass General Brigham Health Plan does not
discriminate against any qualified applicant for
practitioner network membership solely because of
race, color, national origin, ancestry, age, sex, religion,
disability, sexual orientation, type of procedure, or
patient served. Mass General Brigham Health Plan’
credentialing policies do not discriminate against
particular clinicians who service “high-risk”
populations or who specialize in conditions or
procedures requiring costly treatment.
Practitioner rights in the credentialing and
recredentialing processes include:
• The right to review information submitted to
support their credentialing application (except
National Practitioner Data Bank [NPDB] reports,
as required by law)
• The right to correct erroneous information
• The right to be informed of the status of their
credentialing or re-credentialing application,
upon request.
For more information, contact Mass General
Brigham Health Plan Provider Service at 855-444-
4647 or email [email protected]
Sanctioned Providers
To ensure a quality network and the safety of enrolled
members, Mass General Brigham Health Plan reserves
the right to alter a contractual relationship when a
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3-4 2024-05-01
practitioner fails to meet Mass General Brigham
Health Plan’ quality standards.
Mass General Brigham Health Plan monitors the
following activities on an ongoing basis as a part of the
re- credentialing and re-licensure process:
• Sanctioned providers
• Adverse events
• Complaints
Decisions about altering a practitioner’s relationship
with Mass General Brigham Health Plan are guided
by patient care considerations and based on
information submitted by the practitioner as well as
other objective evidence.
An appeal process is available for practitioners who
are not offered network participation after re-
credentialing only. Notification of their right to appeal
a credentialing decision and a description of the
appeal process is included in Mass General Brigham
Health Plan’ letter to the practitioner at the time they
are notified of the adverse credentialing or re-
credentialing decision. Practitioners have the right to
review information submitted to support their
credentialing and re-credentialing application
(excluding NPDB information) at any time. The
practitioner may request to review his or her
credentialing or re-credentialing file in writing,
verbally or electronically, and a member of Mass
General Brigham Health Plan’ Credentialing staff will
contact him or her to schedule a mutually agreed
upon time to review the file. If desired by the
practitioner, copies of the file can be forwarded to the
practitioner by certified, returned receipt mail.
Practitioners have the right to correct erroneous
information submitted to Mass General Brigham
Health Plan in support of their credentialing or re-
credentialing application.
Mass General Brigham Health Plan reports all
terminations of network practitioners for quality-of-
care reasons to the appropriate authorities, including
the NPDB and the state licensing board. Reporting of
practitioners terminated for quality reasons occurs
within 15 calendar days of the practitioner’s final
appeal outcome in accordance with the regulations
governing the NPDB and the procedures set forth
below. The provider can appeal any negative
credentialing decision.
If there is a negative report, disciplinary action,
sanction, or other evidence of serious quality
deficiencies regarding a practitioner, an objective
assessment of the practitioner’s practice is
undertaken by the Mass General Brigham Health Plan
Credentialing Committee to determine whether the
practitioner’s status or contract should be reduced,
suspended, or terminated. Events leading to a change
in the practitioner’s participation status with Mass
General Brigham Health Plan include but are not
limited to:
• Sanctions rendered by a state or federal agency
• Refusal to comply with Mass General Brigham
Health Plan, local, state, or federal requirements
or regulations on clinical or administrative
practices
• A pattern of practice that falls below applicable
standards and expectations
• Failure to maintain full and unrestricted licensure
in the Commonwealth of Massachusetts
• Failure to comply with accepted ethical and
professional standards of behavior when any of
the following situations comes to the attention of
Mass General Brigham Health Plan staff, the
information regarding the practitioner, as well as
all available historical credentialing and
performance information, is presented for review
by the chairperson of the Credentialing
Committee, or his or her designee:
• The practitioner’s application for staff privileges or
membership with any group/facility is denied or
rejected for disciplinary cause or reason
• The practitioner’s staff privileges, membership, or
employment with any group/facility is terminated
or revoked for disciplinary cause or reason
• The practitioner voluntarily accepts, or restrictions
are imposed on, staff privileges, membership, or
employment with any group/facility for
disciplinary cause or reason
• Malpractice complaints
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• Any sanction imposed by the Massachusetts Board
of Registration in Medicine
• A pattern of practice that falls below applicable
standards and expectations
• Failure to maintain full and unrestricted licensure
in the Commonwealth of Massachusetts
• Failure to comply with accepted ethical and
professional standards of behavior
• Refusal to comply with Mass General Brigham
Health Plan, local, state, or federal requirements
or regulations on clinical or administrative
practices
The chairperson, or his or her designee, will make an
immediate and temporary decision on whether to
suspend or reduce the practitioner’s participation
status with Mass General Brigham Health Plan. A
decision to immediately suspend or curtail a
practitioner’s participation status is made when the
event indicates that a practitioner may be a threat to
the health and/or safety of his or her patients and/or
is in a situation where the practitioner cannot serve
the health needs of his or her patients appropriately.
Where a determination that the seriousness of the
deficiency warrants an immediate alteration of a
practitioner’s participation status, the practitioner is
notified in writing that a professional review action
has been brought against him or her, including the
reasons for the action and a summary of the
consideration process and appeal rights.
The practitioner is invited to attend a meeting
within 30 calendar days to have his or her case
heard and provided with the corresponding date,
time, location, and other relevant information.
The practitioner may present appropriate
materials supporting his/her case. After full
consideration of the facts, the committee will
decide as follows:
• Continued full participation
• Continued participation with supervision
• Continued participation with mandatory
education, counseling, and/or training
• Continued participation with limits
• Reduction or restriction of participation privileges
• Suspension from the network for a given period or
until conditions for full participation are met
• Termination from the Mass General Brigham
Health Plan provider network
• The practitioner is notified by registered mail
within 10 business days of the Credentialing
Committee’s determination. When applicable
and depending on the decision, the notification
may include the following information:
• That a professional review action has been
brought against the practitioner, reasons for the
action, and a summary of the appeal rights and
process
• That the practitioner can request an appeal
hearing no later than 30 calendar days from the
date of the letter
• That the practitioner may be represented by an
attorney or another person of his or her choice
during the appeal proceedings
• That if an appeal is requested by the practitioner,
Mass General Brigham Health Plan will appoint a
panel of individuals to review the appeal and
notify the practitioner in writing of the appeal
decision and reasons.
Mass General Brigham Health Plan Provider Service
and other relevant staff are notified of any change in
the practitioner’s relationship with Mass General
Brigham Health Plan, along with notification to the
Executive Office of Health and Human Services
(EOHHS), applicable state licensing boards, the NPDB,
and other applicable entities of any reportable
incidents. Updates to Mass General Brigham Health
Plan’ online Provider Directory are made
immediately.
If the practitioner is a PCP, the practitioner’s
member panel will be closed, and arrangements will
be made for the transfer of the membership to
another credentialed primary care network
provider.
Appeals Process
If a practitioner chooses to appeal a network
participation decision made by Mass General Brigham
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Health Plan, the request must be made in writing
within 30 calendar days from Mass General Brigham
Health Plan’ notification. The notification should
include whether the practitioner will bring an attorney
or another person of his or her choice.
Pending the completion of the appeal process, and
unless specified otherwise, the initial decision of the
Credentialing Committee remains in full force and
effect.
Upon timely receipt of the request, a meeting is
scheduled with Mass General Brigham Health Plan’
Appeals Panel to review the appeal. The Appeals
Panel consists of: Mass General Brigham Health Plan’
Vice President of Provider Network Management,
Mass General Brigham Health Plan’ Chief Medical
Officer and the Directors of Enrollment and Legal,
Regulatory and Compliance. Each panel member can
appoint a designee of his or her choice and Mass
General Brigham Health Plan’ legal counsel will be
present when deemed appropriate.
The practitioner is notified of the Appeals Panel
decision in writing, including the specific reasons for
the decision.
Reporting to Appropriate Authorities
After a final determination has been made resulting in
a practitioner’s termination, a letter is issued to the
practitioner advising him or her of Mass General
Brigham Health Plan’ determination, including its
responsibility to report such termination to the NPDB,
EOHHS, and appropriate state board licensing entities.
The practitioner may dispute the language of the
NPDB or state reports. A dispute can be based upon
any one of the following reasons:
• The factual accuracy of the report
• Whether the report was submitted in accordance
with the NPDB or other state guidelines
• Mass General Brigham Health Plan’ eligibility as an
NPDB reporting entity
Upon receipt, Mass General Brigham Health Plan will
review the applicable reason(s) and make a
determination as to whether any changes should be
made. When applicable, necessary changes are
processed.
Subsequent notification to the practitioner, the NPDB,
applicable state board licensing entities, and EOHHS is
made indicating one of the following actions:
• Void of the initial report
• No action
• Correction to the language reported
When no appeal is initiated by the practitioner within
30 calendar days following notice of the Mass
General Brigham Health Plan decision, or when an
appeal is upheld, the practitioner’s name remains
removed from Mass General Brigham Health Plan’
Provider Directory. When applicable, arrangements
are made by Mass General Brigham Health Plan staff
to have affected members assigned to another
contracted provider.
Credentialing Requirements
To participate in the Mass General Brigham Health
Plan provider network and, where applicable, be listed
in Mass General Brigham Health Plan’ provider
directory, practitioners must be credentialed by Mass
General Brigham Health Plan. Providers listed in the
Provider Directory are those who a member can
choose when accessing care.
Mass General Brigham Health Plan does not recognize
interim/provisional credentialing or providers still in
training. Providers must be fully credentialed before
they can be compensated for care rendered to Mass
General Brigham Health Plan members.
Practitioners seeking enrollment with Mass General
Brigham Health Plan, and who work for a Mass General
Brigham Health Plan-contracted group, must first
submit a request through Mass General Brigham
Health Plan’ Provider Enrollment Portal.
Alternatively, the group can also submit a
completed HCAS Enrollment Form to Mass General
Brigham Health Plan with preliminary information
about the practitioner and his or her practice.
The form may be sent to:
Mass General Brigham Health Plan
Credentialing Department
399 Revolution Drive, Suite 810
Somerville, MA 02145
Fax:
617-526-1982
Email:
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Shortly after receipt and processing of the enrollment
request, the practitioner or his or her credentialing
administrator will receive a welcome packet with
instructions for completing the initial credentialing
submission process by registering with Council for
Affordable Quality Healthcare (CAQH) that contains a
replica of the Integrated Massachusetts Application
(IMA). Those practitioners submitting an enrollment
request who already registered with CAQH (and have
authorized release of their CAQH information to Mass
General Brigham Health Plan) will not receive a
welcome packet, but they may receive an email
requesting that they re-attest to their data. If the
attestation is current, Mass General Brigham Health
Plan will then initiate the credentialing process.
Mass General Brigham Health Plan’ credentialing
process involves accumulating and verifying many
elements of a practitioner’s professional history
including licensure, training, hospital privileges, and
malpractice history. At a minimum, Mass General
Brigham Health Plan is required to:
• Check each applicant with the NPDB
• Verify licensure to practice, including with the
Drug Enforcement Administration (as applicable),
and carry malpractice insurance coverage of
$1,000,000 per occurrence and
• $3,000,000 aggregate
• Determine if an applicant has any pending
Medicare or Medicaid sanctions
• Where applicable, verify that an applicant has
clinical privileges in good standing at a licensed
facility designated by the applicant as the primary
admitting facility. If an applicant does not have
admitting privileges, the applicant must have a
coverage relationship with a Mass General
Brigham Health Plan credentialed provider.
Mass General Brigham Health Plan has a process in
place to provide ongoing performance monitoring of
practitioners between credentialing and re-
credentialing cycles. In addition to monitoring
practitioner performance through member complaints
and grievances, at least twice a month Mass General
Brigham Health Plan’ Credentialing staff checks state
licensing boards’ disciplinary action lists for license
restrictions/sanctions and the Office of the Inspector
General’s latest Exclusion and Reinstatement Lists of
individuals and organizations excluded from
Medicare/Medicaid/federal programs. Complaints
received by Mass General Brigham Health Plan and
sentinel events regarding practitioners are also
compiled periodically for review.
If a credentialed, contracted practitioner has been
disciplined, excluded, or is shown to have other
performance issues after his or her initial
credentialing, Mass General Brigham Health Plan will
immediately take appropriate actions to address the
issue, in accordance with its policies and procedures.
Possible actions taken may range from establishing
corrective action plans with close monitoring for
compliance until the issues are resolved to
reconsideration of the credentialing decision, up to
and including termination from the network. Mass
General Brigham Health Plan also has a process in
place to notify applicable state licensing boards and
the NPDB of any reportable incidents.
The Credentialing Process
Mass General Brigham Health Plan is a member of
HealthCare Administrative Solutions, Inc.
(HCAS). This non-profit entity was founded in
2007 with collaboration from several Massachusetts
health plans to streamline the credentialing and re-
credentialing processes.
Submission of those elements of the credentialing and
re-credentialing transactions that are common to
participating HCAS health plans can occur through a
centralized database. The CAQH allows providers to
submit credentialing information into its Universal
Credentialing Data Source to be used by all HCAS
health plans in which the practitioner participates or is
in the process of contracting.
As part of the full delegation agreement with
Andros Technologies, Inc., Mass General Brigham
Health Plan is committed to the turn-around of
completed credentialing applications submitted by
MDs, DOs, and other PCPs within 30 days of receipt of
a completed application. Upon completion of the
credentialing process, providers are notified within
four business days of the Credentialing Committee
decision and are included in the Mass General
Brigham Health Plan Provider Directory. Providers who
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do not meet the credentialing standards are given an
opportunity to appeal the decision.
The Re-credentialing Process
Re-credentialing occurs in a two-year cycle consistent
with the practitioner’s birth month and year.
A practitioner who has been successfully credentialed
by Mass General Brigham Health Plan, and either
leaves the practitioner network voluntarily or has
been terminated by Mass General Brigham Health
Plan for any reason with a break in service greater
than 30 calendar days, must go through Mass General
Brigham Health Plan’ initial credentialing process
again prior to reinstatement in the network.
Locum Tenens
Mass General Brigham Health Plan defines locum
tenens as a physician covering for another physician
temporarily for six months or less and not subject to
full credentialing. Providers must specifically indicate
that the physician is being enrolled in a locum tenens
capacity. Enrollment for these clinicians require
completion of request in the Mass General Brigham
Health Plan’ Provider Enrollment
Portal or an HCAS Enrollment Form, malpractice
information, as well as hospital privileges or covering
arrangements otherwise.
Locum tenens providers are not eligible to render
and bill for services until written confirmation from
Mass General Brigham Health Plan of their successful
enrollment and are held to the same expectations of
all other Mass General Brigham Health Plan
providers.
If the locum tenens physician will be in place beyond
six months, Mass General Brigham Health Plan must
be notified at least 45 days ahead of time such that
Mass General Brigham Health Plan can initiate the
abbreviated credentialing process. Failure to timely
notify Mass General Brigham Health Plan will result in
claim denials and the retroactive processing of any
denied claim cannot be considered.
Provider Enrollment
Mass General Brigham Health Plan requires that,
when applicable, all providers be credentialed or
enrolled prior to rendering care. Mass General
Brigham Health Plan does not recognize interim or
provisional credentialing of practitioners still in
training. Services rendered prior to a practitioner’s
enrollment by Mass General Brigham Health Plan
cannot be honored. Practitioners seeking enrollment
with Mass General Brigham Health Plan, and
employed by an Mass General Brigham Health Plan
contracted group, must submit a request through
Mass General Brigham Health Plan’ Provider
Enrollment Portal or a completed HCAS Enrollment
Form to Mass General Brigham Health Plan with
preliminary information about the practitioner and
his/her practice.
Provider sites can review a list of all clinicians enrolled
in Mass General Brigham Health Plan, including
original effective dates of the affiliation via the
Provider Roster reports available from the Mass
General Brigham Health Plan Provider Portal
For new Mass General Brigham Health Plan providers,
the practitioner is notified (by letter) of his/her ability
to begin rendering care upon approval for network
participation by Mass General Brigham Health Plan’
Credentialing Committee.
For questions on a clinician’s enrollment status,
email Mass General Brigham Health Plan at
[email protected] or contact Mass General
Brigham Health Plan Provider Service at 855-444-
4647.
MassHealth Provider Enrollment
Requirement
Federal regulations set forth at 42 CFR § 438.602
require that all Mass General Brigham Health Plan
network providers enter into a MassHealth Non-Billing
MCE Network-only Provider Contract or another
MassHealth provider contract. This contract should be
completed within 30 days to receiving the notice.
Visit the following website to complete the contract
process: https://www.mass.gov/forms/submit
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Note: Contracts are to be submitted to MassHealth
directly per the instructions. This specific provider
contract does not require Mass General Brigham
Health Plan network provider to render services to
MassHealth fee-for service members.
Mass General Brigham Health Plan will then forward
you the MassHealth PIDSL number and effective date
that MassHealth assigns to you.
If you do not enter into a MassHealth Non-Billing MCE
Network-only Provider Contract or another
MassHealth provider contract, Mass General Brigham
Health Plan may be required to terminate you from
our ACO (provider network).
Provider Enrollment Changes
To keep accurate network provider information, Mass
General Brigham Health Plan must be promptly
notified in writing of relevant changes pertaining to a
provider’s practice. The primary way to notify Mass
General Brigham Health Plan of enrollment changes is
through the Provider Enrollment Portal within the
Mass General Brigham Health Plan Provider Portal.
The Provider Enrollment Portal gives you easy access
to submit requests such as the following:
• Enroll a new provider into your group
• Terminate an existing provider from your group
• Open and close your panels
• Submit demographic changes
• Generate a complete HCAS form
The Provider Enrollment Portal gives you real time
status information of your enrollment request as
well as send you an email notification when your
request has been completed.
Providers can also submit provider enrollment
changes on the Standardized Information Change
Form or with a signed document on the provider’s
stationery. Completed forms should be emailed to
[email protected]. Verbal requests and/or
those submitted by third-parties or billing agents not
on record as authorized to act on a provider’s behalf
cannot be accepted.
Provider Terminations
For providers terminating from a practice, Mass
General Brigham Health Plan requires written
notification at least 60 days prior to the practitioner’s
termination date unless otherwise agreed upon.
The notification must be submitted through the
Provider Enrollment Portal on the Mass General
Brigham Health Plan Provider Portal, on the
standardized provider information change form, or
using a similar document on the provider’s stationery
that includes at a minimum:
• The provider’s name
• NPI number
• Effective date of termination
• Reason for termination
• If PCP, panel re-assignment instructions
• Signature and title of the person submitting the
notification
Upon receipt of the notification, Mass General
Brigham Health Plan’ staff will work with affected
members, the provider’s office, and when applicable,
specialty providers, to ensure continuity of care.
Involuntary terminations (those initiated by Mass
General Brigham Health Plan) will include notification
to the provider and the practice as needed.
Except when a provider’s termination is based
upon quality related issues or fraud, Mass General
Brigham Health Plan may allow continuation of
treatment for covered services for:
• Up to 30 days following the effective date of the
termination if the provider is a PCP
• Up to 90 days for members undergoing active
treatment for a chronic or acute medical
condition; or through the lesser of the current
period of active treatment with the treating
provider
• Members in their second or third trimester of
pregnancy with the provider treating the member
in conjunction with said pregnancy through the
initial post-partum visit.
• Services for members who are terminally ill until
their death.
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The provider must accept payment at the applicable
fee schedule as payment in full and must not seek any
payment from the member for covered services. The
provider must adhere to Mass General Brigham Health
Plan’ quality assurance programs and other Mass
General Brigham Health Plan policies and procedures
including, but not limited to, procedures regarding
prior authorization and notification.
For members who will continue receiving care from
the provider, Mass General Brigham Health Plan
Clinical staff will contact the provider to obtain more
information including confirmation of any scheduled
services to be authorized on an out-of- network basis,
with the provider being notified accordingly.
Claims for members who continue to see a
terminated provider without Mass General Brigham
Health Plan’ knowledge will be automatically denied.
Disputes in these cases can be addressed through
Mass General Brigham Health Plan’ administrative
appeals process and, depending on the outcome, the
provider will be reimbursed for services rendered at
the applicable fee schedule.
Panel Changes
Panel closure notification does not apply to specialty
providers. Mass General Brigham Health Plan requires
that a practice maintain at least 50 percent of PCP
panels open at all times. A PCP panel may not be
closed to an existing patient who has transferred to
Mass General Brigham Health Plan from another
health plan.
PCPs may not close their panels to a specific Mass
General Brigham Health Plan product. When a PCP’s
panel reaches 1,500 members, the provider must
request to close his or her panel by providing Mass
General Brigham Health Plan with 30 days advance
written notice. The PCP may decline new or additional
Mass General Brigham Health Plan members only if his
or her panel is also closed to all other health plans.
Members who had selected the PCP prior to Mass
General Brigham Health Plan’ notification must be
allowed assignment to his/her panel. Other exception
requests for PCPs with closed panels will be discussed
with the PCP’s office and processed only upon
obtaining verbal approval. PCPs are required to notify
Mass General Brigham Health Plan through the
Provider Enrollment Portal of any changes in their
panels. The PCP can also submit a notification letter
that must include the effective date of the panel
closure and whenever possible, the anticipated
duration of such closure. The PCP’s panel status will
be reflected accordingly in the Mass General Brigham
Health Plan Provider Directory. A Mass General
Brigham Health Plan Provider Network Account
Executive reviews rosters at each provider visit as
additional confirmation of panel status, to monitor the
duration of closed panels, and to ensure accuracy of
provider enrollment information and adequate access.
Through the Mass General Brigham Health Plan
Provider Portal, Mass General Brigham Health Plan
provides updated PCP assignment information daily to
PCP offices. Discrepancies in a member’s PCP
information can be systematically corrected by the
PCP office without assistance from Mass General
Brigham Health Plan.
• This option is limited to PCP changes within the
same site, to a PCP with an open panel.
• Changes to a member’s PCP and Primary Care Site
must be initiated by the member calling Mass
General Brigham Health Plan Member Service or
by submitting the request through
provider.massgeneralbrighamhealthplan.org and
attesting to obtaining the member’s consent.
Behavioral Health Care Integration
Mass General Brigham Health Plan and its designated
behavioral health contractor, Optum, are committed
to fully integrating Mass General Brigham ACO
patients’ medical and behavioral health care. General
Brigham Health Plan recognizes the importance of
working collaboratively to create a coordinated
treatment system where all providers work together
to support the member in a seamless system of care.
To this end, Mass General Brigham Health Plan has
worked closely with Optum to develop specific
programs and provider procedures that standardize
communication and linkage between Mass General
Brigham ACO members’ primary care and behavioral
health providers. Linkage between all providers
(primary care, mental health, and substance use
providers, as well as state agencies) supports member
access to medical and behavioral health services,
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reduces the occurrence of over-and-underutilization,
and provides coordination within the treatment
delivery system.
Communication among providers also improves the
overall quality of both primary care and behavioral
health services by increasing the early detection of
medical and behavioral health problems, facilitating
authorizations for appropriate services, and
maintaining continuity of care.
Provider Rights and Responsibilities
Mass General Brigham Health Plan does not prohibit
or restrict network providers, acting within the lawful
scope of practice, from advising or giving treatment
options, including any alternative treatment.
To ensure effective relationships, and to be consistent
with our joint commitment to enhance the quality of
life for all Mass General Brigham ACO members, we
require network providers to:
• Accept Mass General Brigham ACO members as
patients to the extent other health plan members
are accepted.
• Make Mass General Brigham ACO patients aware
of all available care options, including clinical care
management. Treat Mass General Brigham ACO
patients as equals to all other patients.
• Be active participants in discharge planning
and/or other coordination of care activities.
• Comply with medical records requirements
relative to proper documentation and storage,
allowing access for review by individuals acting
on Mass General Brigham Health Plan’ behalf and
supporting appropriate medical record information
exchange at a provider and/or patient’s request.
• Comply with patient access standards as defined
within this manual. Remain in good standing with
local and/or federal agencies.
• Be responsive to the cultural, linguistic, and other
needs of Mass General Brigham Health Plan
members.
• When applicable, inform Mass General Brigham
ACO patients of advanced directive concurrent
with appropriate medical records documentation.
• Coordinate care with other clinicians through
notification of findings, transfer of medical
records, etc., to enhance continuity of care and
optimal health.
• Coordinate transfers from one behavioral health
provider to another. The transferring provider
must obtain a release of information from the
member and send a case summary, including the
reason for the transition to the new provider
• Report findings to local agencies as mandated
and to Mass General Brigham Health Plan when
appropriate.
• Promptly notify Mass General Brigham Health
Plan of changes in their contact information,
panel status, and other relevant information.
• Respect and support Mass General Brigham
Health Plan Members Rights and Responsibilities.
• Of equal importance, Mass General Brigham ACO
providers have the right to:
• Receive written notice of network participation
decisions.
• Exercise their reimbursement and other options
as defined within this manual and/or the Mass
General Brigham Health Plan Provider
Agreement.
• Communicate openly with patients about
diagnostic and treatment options.
• Expect Mass General Brigham Health Plan’s
adherence to credentialing decisions as
defined herein.
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Access and Availability Requirements
Mass General Brigham Health Plan’ Provider Network
Management staff regularly evaluates access and
availability and the comprehensiveness of Mass
General Brigham Health Plan’ provider networks.
Access and availability of acute care facilities, PCPs
and obstetricians/gynecologists are evaluated at least
quarterly. Access and availability of high-volume
specialty care practitioners is evaluated at least
annually. High- volume specialties are defined as the
top five specialties based on claim volume.
Mass General Brigham Health Plan strives to ensure
the availability of practitioners who are multilingual,
understand and comply with state and federal laws
requiring that practitioners assist members with
skilled medical interpreters and resources, and are
responsive to the linguistic, cultural, ethnic, and/or
other unique needs of minority groups and special
populations.
At least annually, Mass General Brigham Health Plan
reviews data on Mass General Brigham ACO patients’
cultural, ethnic, racial, and linguistic needs to define
quality initiatives, inform interventions, and assess
availability of practitioners within defined
geographical areas to meet the needs and preferences
of our membership.
Member Complaints and Grievances
Mass General Brigham Health Plan is strongly
committed to ensuring member satisfaction and the
timely resolution of reported concerns regarding a
Availability and access standards are defined as
follows:
Provider
Access Ratio to
Members
Availability by Geographic Standards *
Primary Care
1:750
Two primary care providers within 15 miles or 30 minutes travel time from
member’s residence (except Oaks Bluff and Nantucket which are within 40 miles
or 40 minutes from a member’s residence)
OB/GYN
Specialists
1:500
One provider within 15 miles or 30 minutes travel time from member’s
residence
High Volume
Specialists
1:1500
One provider within 20 miles or 40 minutes travel time from member’s
residence
Acute Care
Facilities
N/A
One facility within 20 miles or 40 minutes travel time from member’s residence
Rehabilitation
Facility
N/A
One facility within 30 miles or 60 minutes travel time from member’s residence
Urgent Care
Services
N/A
One facility within 15 miles or 30 minutes travel time from member’s residence
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Mass General Brigham Health Plan reserves the right
to either expand or limit its provider networks
according to Mass General Brigham Health Plan’
business objectives. In determining network expansion
needs, Mass General Brigham Health Plan evaluates
these availability and access standards along with
other criteria.
Cultural Competency
Mass General Brigham Health Plan has a diverse
patient population in terms of linguistic abilities and
cultural and ethnic backgrounds. To promote access to
clinicians who have the ability to communicate with
the member in a linguistically appropriate and
culturally sensitive manner, Mass General Brigham
Health Plan uses a number of strategies to capture
robust and detailed linguistic, ethnic, and cultural data
on our members, including the use of health needs
assessment tools and querying members upon contact
with Mass General Brigham Health Plan Member
Service. Mass General Brigham Health Plan captures
linguistic capabilities of providers as part of the
credentialing process for individual clinicians.
For access and availability assessment, the member’s
self-reported primary language serves as a measure of
their linguistic needs and preferences as well as a
proxy for cultural and ethnic identity. The providers’
self-report of languages spoken serves as the measure
of their linguistic ability and a proxy for cultural and
ethnic backgrounds. Mass General Brigham Health
Plan also employs US Census Data on prevalent non-
English languages spoken in Massachusetts and
identifies those languages spoken by 10,000 or more
individuals, five years and older, within each
Massachusetts county.
Wait Time Access Standards
Mass General Brigham Health Plan Mass General
Brigham Health Plan providers must ensure the
availability of prompt provider consultation, including
arrangements to assure coverage for patients after
hours. Mass General Brigham Health Plan requires the
hours of operation offered for all members to be the
same regardless of their coverage.
In addition to after-hours access standards, patients
should be seen within a reasonable time after their
arrival. A reasonable time is defined as within 30
minutes of the appointment time.
Patient calls regarding active clinical problems
returned within the hour when clinically appropriate,
or on a same day basis otherwise. Telephone calls
regarding routine administrative requests should be
returned within two business days.
Mass General Brigham Health Plan is required to
monitor and report on member access to specific
primary care and specialty services. This is done with
an access and availability survey administered by Mass
General Brigham Health Plan Provider Network
Management Department.
The survey seeks responses as to the availability or
wait time access for services
such as:
• Emergency care
• Urgent care
• Routine symptomatic care
• Routine non-symptomatic care
• After-hours care
• Department of Social Service (DSS) custody
initial exam
Fraud, Waste and Abuse
Fraud Prevention
Mass General Brigham Health Plan expects
providers to comply with all federal and state
regulations that prohibit fraudulent behavior,
including but not limited to:
• Recording clear and accurate documentation of all
services rendered in a timely manner as close as
possible to the date of service
• Not signing blank certification forms that are used
by suppliers to justify payment for home oxygen,
wheelchairs, and other medical equipment
• Being suspicious of any vendor offering discounts,
free services, or cash in exchange for referrals
• Refusing to certify the need for medical supplies
for patients not seen and/or examined.
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• Specifying the diagnosis when ordering a
particular service (e.g., lab test)
• Knowing and adhering to the practice’s billing
policies and procedures
• Verifying the identity of patients since insurance
cards can be borrowed, stolen, and fabricated
• Carefully scrutinizing requests for controlled
substances, particularly with new patients.
Reporting Health Care Fraud
Providers who suspect health care fraud should
report any suspicions to their organization’s
Compliance Office or Executive Director.
Suspicions or concerns involving a Mass General
Brigham Health Plan member or clinician can be
reported to Mass General Brigham Health Plan’s
Compliance Office in writing or by email. These
concerns can also be reported anonymously to the
Mass General Brigham Health Plan Compliance
Hotline 24 hours a day, seven days a week. The
Hotline is operated by an independent company and
is not staffed by Mass General Brigham Health Plan
employees.
Fraudulent acts or suspicions may be reported as
follows:
Mail:
Mass General Brigham Health Plan Legal, Regulatory
and Compliance Department
399 Revolution Drive
Suite 810
Boston, MA 02210
Phone:
Mass General Brigham Health Plan
Legal, Regulatory & Compliance Department
800-433-5556
(then dial 0 to have your call directed)
Mass General Brigham Health Plan
Compliance Hotline (anonymous)
844-556-2925
Website
Submit a report through our Compliance website using
this link:
EthicsPoint - Mass General Brigham Health Plan
False Claims Act
In complying with our obligations under the
Deficit Reduction Act of 2005, Mass General Brigham
Health Plan provides detailed information to our
employees, contractors, and agents regarding the
False Claims Act and comparable state antifraud
statutes, including whistleblower protections. To that
end, Mass General Brigham Health Plan has
developed and continues to refine our policies and
procedures regarding fraud and abuse detection,
prevention, and reporting including but not limited
to the following documents:
• Code of Ethics
• Compliance Hotline Policy
• Non-Retaliation for Reporting of Compliance
Violations
• Fraud Reporting and Whistleblower Protections
Policy
Waste Identification, Reimbursement
Validation and Recoveries
Mass General Brigham Health Plan’ Payment Integrity
department is responsible for identifying waste and
for validating all claims reimbursements. The
department is responsible for identifying and
recovering claim overpayments, which may be the
result of billing errors, payment errors, unbundling,
duplicates, retroactive contract reviews, or other
claims payment anomalies. The department performs
several operational activities to ensure the accuracy
of providers’ billing submissions and of claims
payments. The Payment Integrity department also
utilizes internal and external resources to prevent
incorrect payment of claims and will initiate recovery
if and when overpaid claims are identified.
Mass General Brigham Health Plan has established an
overpayment identification and reimbursement
validation audit process to verify the accuracy of
charges and payments appearing on provider (facility,
physician, and ancillary provider) claims and to ensure
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that all charges and payments are consistent with
Mass General Brigham Health Plan Provider
Agreements, Mass General Brigham Health Plan’
policies and procedures, and applicable nationally
recognized medical, claims administration, and claims
reimbursement policies. Mass General Brigham Health
Plan’ policies, which include but not limited to:
medical policies; claims administration rules; and
payment guidelines; apply to all reimbursement and
claims matters. In any matter where Mass General
Brigham Health Plan does not maintain an applicable
policy, Mass General Brigham Health Plan adopts and
follows industry standards and policies relating to
procedural coding, medical claims administration, and
medical claims reimbursement which are recognized
by governmental payers, such as the Centers for
Medicare & Medicaid Services (CMS), national health
insurance carrier organizations, and the American
Medical Association (AMA).
Mass General Brigham Health Plan may conduct
reimbursement validation audits on claims that Mass
General Brigham Health Plan has paid during the
current fiscal year or has paid during the two (2) prior
fiscal years. Mass General Brigham Health Plan may
also initiate reimbursement validation audits up to six
(6) years after a claim payment to investigate whether
a provider has engaged in billing practices that may
constitute fraud or abuse.
Provider reimbursement validation audits can take
place in two (2) audit venues: on-site and/or off-site
audits. Mass General Brigham Health Plan
determines the venue, or combination of venues,
that its Audit Specialists shall employ in an audit.
General Claims Audits
General post-payment claims audits are conducted to
identify the accuracy of charges and the consistency of
claims reimbursement with Mass General Brigham
Health Plan’ policies, Provider Agreements, Payment
Guidelines, and applicable nationally recognized
medical claims reimbursement and administration
policies, including but not limited to: CPT, MassHealth,
and CMS guidelines. Audit topics can include, but are
not limited to:
• Overpayments due to incorrect setup or
update of contract/fee schedules in the
system
• Overpayments due to claims paid based upon
conflicting authorizations or duplicate
payments
• Overpayments resulting from incorrect
revenue/procedure codes
• Provider billing for services at a higher level
than provided.
• Provider billing for services not documented
and not provided
• Incorrect coding, including unbundling
component service codes, modifier usage,
units of service, and/or duplicate payments
• Historical claim audits to include the global
surgical period for codes submitted on the
current claim
• Medical necessity based on Mass General Brigham
Health Plan, MassHealth, and/or CMS guidelines
as applicable to the member benefit plan
When an overpayment event is identified, Mass
General Brigham Health Plan Payment Integrity will
begin its overpayment recovery process by sending
written notification to the provider containing
instructions for the process (“Notification of Audit”).
In the event the provider does not agree with the
identified overpayment amount, the provider should
follow the process described in the “Provider Audit
Appeals” section of the Provider Manual. If providers
do not agree with Payment Integrity’s findings,
providers should follow the appeal process outlined
within the overpayment notification or findings letter
to ensure their appeal rights are preserved and
appropriately addressed. Providers who remain
unsatisfied upon resolution of the appeal should refer
to the instructions outlined within the dispute
determination letter.
If Mass General Brigham Health Plan does not hear
from the provider within 30 days from either the
initial written overpayment notification or the dispute
determination notification, the final overpayment
amount will be offset from future claims payments. In
cases where recovery through offsetting will take
longer than six months, Mass General Brigham Health
Plan reserves the right to seek additional legal
recourse such as referral to a collection service.
Mass General Brigham Health Plan—Provider Manual 3 –Provider Management
3-16 2024-05-01
On-Site Audit
In the on-site audit, a Mass General Brigham Health
Plan Audit Specialist or designated party conducts the
audit of designated medical records at the provider’s
site. For on-site audits, Mass General Brigham Health
Plan requests that the provider make a suitable work
area for the Audit Specialist to perform the audit
activities while on-site during the duration of the
audit. Mass General Brigham Health Plan requires that
a provider schedule an audit at a mutually convenient
time for Mass General Brigham Health Plan’ Audit
Specialist, medical records department, and the
patient account representative. The provider and
Mass General Brigham Health Plan agree that
cancellation of a scheduled audit requires written
notification no less than fifteen (15) business days
prior to the scheduled audit and should be sent to
Mass General Brigham Health Plan’ Manager of
Provider Audit and the designated facility
representative.
The inspection and copying of medical records are
conducted in compliance with the provider’s standard
policies that govern such processes and that are
applied uniformly to all payers. Along with the medical
records, the provider must make available the
pharmacy profile and corresponding fee book. The fee
book must include all updated versions in electronic
format suitable for use on a personal computer (Excel
or other program), unless the Provider makes other
arrangements with the Mass General Brigham Health
Plan Manager of Provider Audit. All designated
records must be produced within twenty-one (21)
days of the request by Mass General Brigham Health
Plan. Unless the parties agree otherwise, the provider
must schedule the audit to occur no later than thirty
(30) business days from the request.
At the conclusion of the audit, and if the provider
agrees with the findings, the Audit Specialist provides
the provider a dated copy of the signed, finalized
Discrepancy Report. If the provider does not agree
with the audit findings at the time of the exit
interview, the provider has thirty (30) business days to
submit additional supporting documentation.
Mass General Brigham Health Plan’ Claims department
retracts all audit discrepancies thirty (30) days after
the signed, finalized Discrepancy Report. If the
Provider fails to provide additional supporting
documentation and/or does not respond within thirty
(30) days, Mass General Brigham Health Plan’ Claims
department retracts all audit discrepancies.
Off-Site Audit
The second reimbursement validation audit venue is
the off-site audit in which the Mass General Brigham
Health Plan Audit Specialist or designated party
requests specific medical record information from the
provider be sent to Mass General Brigham Health Plan
for review.
Pursuant to Mass General Brigham Health Plan’
provider agreements, Mass General Brigham Health
Plan has the right to inspect, review, and make copies
of records related to an audit. All requests to inspect,
review, and make copies of medical records are
submitted to the provider in writing. Mass General
Brigham Health Plan specifies whether the provider
must make the original medical records or copies of
the requested records available for inspection.
Provider Appeals
If a provider disagrees with Mass General Brigham
Health Plan’ audit findings, the provider may appeal
the audit findings by submitting a request for an
appeal to the Mass General Brigham Health Plan
Provider Appeals department or designated party.
Please refer to Section 10, “Provider Audit Appeals”
for more information.
In accordance with the Mass General Brigham
Health Plan agreement in effect with the provider,
Members cannot be billed for audit discrepancies.
Mass General Brigham Health Plan strictly adheres to
state and federal requirements regarding
confidentiality of patient medical records. A separate
patient authorization is provided when required by
law. In accordance with the Mass General Brigham
Health Plan agreement in effect, patients are not
billed for audit discrepancies.
Mass General Brigham Health Plan—Provider Manual 3 –Provider Management
3-17 2024-05-01
Fraud, Abuse, and the Special Investigations
Unit
Mass General Brigham Health Plan receives state and
federal funding for payment of services provided to
our members. In accepting claims payment from Mass
General Brigham Health Plan, health care providers
are receiving state and federal program funds and are
therefore subject to all applicable federal and/or state
laws and regulations relating to this program.
Violations of these laws and regulations may be
considered fraud or abuse against the Medicaid
program. As a provider, you are responsible for
knowing and abiding by all applicable state and
federal regulations.
Mass General Brigham Health Plan is dedicated to
eradicating fraud and abuse from its programs and
cooperates in fraud and abuse investigations
conducted by state and/or federal agencies, including:
the Attorney General’s Office; the Federal Bureau of
Investigation; the Drug Enforcement Administration;
the Health and Human Services Office of Inspector
General; as well as local authorities. As part of Mass
General Brigham Health Plan’ responsibilities, the
Payment Integrity department is responsible for
identifying and recovering claim overpayments
resulting from a variety of issues. The department
performs several operational activities to detect and
prevent fraudulent, abusive, or wasteful activities.
Examples of fraudulent/abusive activities include, but
are not limited to:
• Billing for services not rendered or not medically
necessary
• Submitting false information to obtain
authorizations to furnish services or items to
Medicaid recipients
• Prescribing items or referring services which are
not medically necessary
• Misrepresenting services rendered
• Submitting a claim for provider services on behalf
of an individual who is unlicensed, or who has
been excluded from participation in the Medicare
and Medicaid programs
• Retaining Medicaid funds that were improperly
paid
• Billing Medicaid recipients for covered services
Mass General Brigham Health Plan, through its
Special Investigations Unit, investigates all reports of
fraud and/or abuse committed by members and
providers. Credible allegations of fraud or abuse will
be reported to our partners within the government.
Mass General Brigham Health Plan may also take any
number of actions to resolve fraud or abuse
allegations, including medical record audits,
instituting prepayment review of a provider’s claims,
stopping payment on a provider’s claims, provider
education, and/or demanding recovery for
discovered overpayments. Moreover, depending on
the severity of the fraud/abuse finding, Mass General
Brigham Health Plan reserves the right to impose
sanctions, including and up to terminating the
provider from Mass General Brigham Health Plan’
network. As stated above, Mass General Brigham
Health Plan seeks recovery of all excess payments
discovered as a result of its fraud and abuse
operational efforts.
When an overpayment event is identified, Mass
General Brigham Health Plan will begin its
overpayment recovery process by sending written
notification to the provider containing instructions
for the process (“Notification of Audit”). In the event
the provider does not agree with the identified
overpayment amount, the provider should follow the
process described in the “Provider Audit Appeals”
section of the Provider Manual. If Mass General
Brigham Health Plan does not hear from the provider
in 30 days from either the initial written
overpayment notification or the dispute
determination notification, the final overpayment
amount will be offset from future claims payments.
In cases where recovery through offsetting will take
longer than six months, Mass General Brigham
Health Plan reserves the right to seek additional legal
recourse such as referral to a collection service.
Preservation of Records and Data
In accordance with the provider agreement, network
providers and Mass General Brigham Health Plan shall
each preserve all books, records, and data that are
required to be maintained for a period of seven years
or longer, as required by law from the date of final
Mass General Brigham Health Plan—Provider Manual 3 –Provider Management
3-18 2024-05-01
payment under the agreement for any specific
contract year.
During the term of this agreement, access to these
items shall be provided at the designated facility or
Mass General Brigham Health Plan offices in
Massachusetts at reasonable times. The facility and
Mass General Brigham Health Plan shall retain such
documents that are pertinent to adjudicatory
proceedings, audits, or other actions, including
appeals, commenced during seven years, or longer as
required by law after any specific contract year, until
such proceedings have reached final disposition or
until resolution of all issues if such disposition or
resolution occurs beyond the end of the seven-year
period.
If any litigation, claim, negotiation, audit, or other
action involving the records is initiated before the
expiration of the applicable retention period, all
records shall be retained until completion of the
action, and resolution of all issues that arise from it, or
until the end of the retention period, whichever is
later.
Furthermore, any such records shall be maintained
upon any allegation of fraud or abuse or upon request
by Mass General Brigham Health Plan or any state or
federal government agency, for potential use in a
specific purpose or investigation or as otherwise
required by law. These records shall be maintained for
a period of time determined by the requesting entity
and at least as long as until completion of the action
and resolution of all issues that arise from it or until
the end of the retention period, whichever is later.
Code of Ethics
Concerns regarding Mass General Brigham Health
Plan’ adherence to our Code of Ethics should be
reported to Mass General Brigham Health Plan’s
Compliance Office in writing or by email. These
concerns can also be reported anonymously to the
Mass General Brigham Health Plan Compliance
Hotline 24 hours a day, seven days a week.
Provider Marketing Activities
Any activities occurring at or originating from a
provider site whereby Mass General Brigham Health
Plan staff or designees, including physicians and office
staff, personally present Mass General Brigham Plan
marketing materials or other marketing materials to
members that can reasonably be determined to
influence the patient to enroll in Mass General
Brigham Plan Mass r to disenroll from Mass General
Brigham Plan are prohibited. This includes direct mail
campaigns sent by the provider site to its patients who
are members. The exception is the of posting written
materials that have been pre-approved by EOHHS at
provider sites and posting written promotional
marketing materials at network provider sites
throughout Mass General Brigham Plan service area.
“Hold Harmless” Provision
Providers contractually agree that in no event,
including, but not limited to, non-payment by Mass
General Brigham Health Plan, Mass General Brigham
Health Plan’s insolvency, or breach of the Provider
Agreement, should a provider or any of its medical
personnel bill, charge, collect a deposit from, or have
any recourse against any Mass General Brigham
Health Plan patient or person, other than Mass
General Brigham Health Plan, acting on their behalf
for services provided. The provider must not solicit or
require from any member, or in any other way,
payment of any additional fee as a condition for
receiving care. Providers must look solely to Mass
General Brigham Health Plan for payment with respect
to covered services rendered to all Mass General
Brigham Health Plan members.
This provision does not prohibit collection of
supplemental charges or copayments on Mass General
Brigham Health Plan’s behalf made in accordance with
the terms of the applicable Subscriber Group
Agreement between Mass General Brigham Health
Plan and the member.
If you have questions about this contract provision,
please contact your Mass General Brigham Health
Plan Provider Network Account Executive.
Mass General Brigham Health Plan—Provider Manual 3 –Provider Management
3-19 2024-05-01
Provider Notification and Training
Mass General Brigham Health Plans’ Provider Network
Management Department works in partnership with
provider offices to build and maintain positive working
relationships and respond to the needs of both
providers and members.
Mass General Brigham Health Plan believes in keeping
providers informed and uses direct mail, newsletters,
and other vehicles for communicating policy,
procedural changes, and/or pertinent updates and
information. The provider network’s implementation
and adherence to communicated procedural changes
is monitored with internal reports, provider site visits,
reported member grievances, and other resources.
Providers receive a minimum of 30 days advanced
notice on any changes that may affect how they do
business with Mass General Brigham Health Plan.
Where a policy or procedure change results in
modification in payments or covered services or
otherwise substantially impacts network providers,
notification will be made at least 60 days prior to the
effective date unless mandated sooner by state or
federal agencies.
Mass General Brigham Health Plan “Provider
Administrative Newsletter” is our monthly e-
newsletter for notifying our network of important
changes and updates, including revisions to the Mass
General Brigham Health Plan Provider Payment
Guidelines and the Provider Manual.
Providers are strongly encouraged to sign up to
receive Mass General Brigham Health Plan’
updates by visiting
Massgeneralbrighamhealthplan.org/providers/ed
ucation.
Provider Network Account Executives incorporate
provider notifications into their agenda for provider
visits to reiterate Mass General Brigham Health Plans’
provider notifications and to address any need for
clarification. Mass General Brigham Health Plan also
hosts periodic forums for network providers, focusing
on administrative and clinical topics, as well as policy
and procedural changes. These forums may be offered
in person or with a “webinar” option.
Role of the Mass General Brigham
Health Plan Provider Network Account
Executive
The Provider Network Account Executive serves as
the primary liaison between Mass General Brigham
Health Plan and our provider network. Provider
Network Account Executives work in partnership with
Mass General Brigham Health Plans’ Contracting
Department and other staff in administering
contractual provisions of the Provider Agreement
and/or to ensure contract compliance.
Provider Network Account Executives meet
regularly with designated staff within their
provider territories to:
• Coordinate and conduct on-site training and
educational programs
• Respond to inquiries related to policies,
procedures, and operational issues
• Facilitate problem resolution
• Manage the flow of information to and from
provider offices
• Ensure contract compliance
• Monitor performance patterns
Mass General Brigham Health Plan—Provider Manual 4 –Provider Portal
5-0 2024-05-01
Section 4: Provider portal
Overview 4-1
Using the Provider Portal 4-1
Member Eligibility 4-1
Claims Status 4-1
Explanation of Payments (EOPs) 4-1
Electronic Funds Transfer and Electronic
Remittance Advice 4-1
Referrals and Authorizations 4-1
PCP Panel Status and Changes within
Your Practice Site 4-1
Reports 4-2
Clinical Reports 4-2
Site Documents 4-2
User Administrator Functions 4-2
Mass General Brigham Health Plan—Provider Manual 4 –Provider Portal
5-1 2024-05-01
Section 4: Provider portal
Overview
Mass General Brigham Health Plan providers and
third-party billers are required to register and actively
use provider.massgeneralbrighamhealthplan.org.
Mass General Brigham Health Plan’s secure provider
portal. Through the provider portal, users have access
to a variety of transactions in a self-service capacity.
The Provider Portal allows providers access to patient
information under the context of the provider site to
which the user is associated. Mass General Brigham
Health Plan Provider Portal supports access to
multiple provider sites with a single account (if
required).
Mass General Brigham Health Plan strives to protect
the privacy of each member’s Protected Health
Information (PHI) and other personally identifiable
information. User actions are audited regularly. Your
access to the Provider Portal is subject to the approval
of the designated user administrator of the provider
site you are associated with, as well as Mass General
Brigham Health Plan.
User access to their provider site information must be
renewed every 180 days. Accounts inactive for 30
days or more are subject to automatic terminations.
The provider portal is your primary point of contact
when you need to conduct the following transactions
with Mass General Brigham Health Plan. Only
inquiries that cannot be addressed via the provider
portal should be directed to Mass General Brigham
Health Plan Provider Service at
Using the Provider Portal
Member Eligibility
The provider portal is designed to give contracted
providers around the clock access to member
information. Eligibility information is updated
immediately after any changes to ensure the most up-
to-date information is displayed.
Providers are responsible for verifying member
eligibility daily through the provider portal prior to
rendering services.
Claims Status
The provider portal is your primary point of contact
when you need to check claim status with Mass
General Brigham Health Plan. A user can verify the
status of a submitted claim while in process and/or
finalized by Mass General Brigham Health Plan. Only
limited claim status can be obtained by calling Mass
General Brigham Health Plan Provider Service or by
emailing them directly at
Explanation of Payments (EOPs)
Providers have instant access to current and historical
copies of Mass General Brigham Health Plan EOPs as
downloadable PDFs Providers can access EOPs by
claim number from the ECHO Provider Payments
Portal at providerspayment.com. To search for an EOP
by date range and to see a detailed explanation of
payment for each transaction, log into
providerpayments.com or create a new account using
your TIN and an ECHO® draft number and payment
amount.
Virtual Credit Card (VCC), Electronic Funds
Transfer and Electronic Remittance Advice
Providers are required to register for Electronic Funds
Transfer (EFT) and Electronic Remittance Advice
(ERA/835). Providers who are not registered to
receive payments electronically will be automatically
enrolled in the Virtual Credit Card payment option.
If you are enrolled in this payment method, each
explanation of payment (EOP) will contain a virtual
credit card with a number unique to that payment
transaction and an instruction page for processing.
To sign up for EFT payments, Providers will need to
enroll through the ECHO Provider EFT/ERA Enrollment
Once registration is complete, providers will no longer
receive paper checks. Providers can now access their
ERA (835 files) from their designated clearinghouse or
by enrolling through the ECHO Provider EFT/ERA
Enrollment.
Mass General Brigham Health Plan—Provider Manual 4 –Provider Portal
5-2 2024-05-01
Referrals and Authorizations
Referrals and prior authorizations are submitted
through the provider portal. Clinical documentation
should be uploaded to support an authorization
request. As a MGB ACO member, referrals are not
required for in-network providers.
The provider portal provides real-time access to
authorization and referral status requests. Providers
should refer to the provider portal for status inquiries.
A report is available to verify the existence of any
required prior authorization and/or referral for
patients referred to the provider’s office by another
provider.
PCP Panel Status and Changes within Your
Practice Site
Through the provider portal, Mass General Brigham
Health Plan provides updated PCP assignment
information daily to PCP offices. Discrepancies in a
patient’s PCP information can be systematically
corrected by the PCP office through the Mass General
Brigham Health Plan Provider Portal or initiated by
the patient by calling Mass General Brigham Health
Plan Member Service.
The primary way to notify Mass General Brigham
Health Plan of enrollment changes is through the
provider portal. Requests that can be submitted
through the provider portal include:
• Enroll a new clinician into your group
• Terminate an existing clinician from your group
• Open and close your panels
• Provider demographic changes
Through the provider portal, you can also view real
time status information on your enrollment request
as well as receive email notification when your
request has been completed.
Reports
The Enrollment Reports function is divided into four
sections:
• Member Roster Report—Allows you to download a
complete listing of patients by provider.
• Member Transaction Report—Displays member
enrollment changes for your site.
• Redetermination Report —This report will display all
members for the currently selected site with recent
Medicaid and Connector redetermination dates.
• Site Provider Roster Report—Displays a current
listing of enrolled practitioners for your site.
Providers are required to regularly review this report
and notify Mass General Brigham Health Plan of any
changes to their roster.
Clinical Reports
Provider can access site-based member utilization
data on ER utilization, immunization rates, and other
disease management (e.g., asthma, diabetes).
Site Documents
Providers have access to securely retrieve sensitive
reports and other data requested of Mass General
Brigham Health Plan.
User Administrator Functions
All sites must have at least one designated User
Administrator to manage user accounts and
permissions for your practice. The User Administrator
has access to view all Provider Portal users registered
for the site and change permissions as needed.
Request for new access within your site must be
approved by your User Administrator.
To enroll, please visit
provider.massgeneralbrighamhealthplan.org and
follow the easy registration instructions or consult
with your site’s appointed User Administrator.
For detailed step-by-step instructions on the provider
portal functionality please refer to the provider portal
user guide.
Providers needing more help can email*
*Please do not send Protected Health Information (PHI) through
unsecured email.
Mass General Brigham Health Plan—Provider Manual 5 –Quality Management Program
5-0 2024-05-01
Section 5: Quality management program
Overview 5-1
Scope 5-2
MassHealth ACO Quality Measures 5-3
Mass General Brigham Health Plan Board
of Directors 5-3
Quality Program Committee (QPC) 5-3
Quality Improvement Committee (QIC) 5-4
Performance Reporting and Improvement 5-4
Provider Profiling System 5-4
Reporting 5-4
Clinical Practice Guidelines 5-4
Health Care Access Standards 5-5
Waiting Room Wait Time 5-6
Medical Records and Office Site Audits 5-6
Medical Records Documentation Standards 5-7
Medical Records Documentation Guidelines 5-8
Additional Pediatric Documentation
Standards 5-11
Exposure to Lead Risk Assessment 5-13
Tuberculin Test 5-13
Early and Periodic Screening and Diagnostic
Testing (EPSDT) 5-13
Other Testing 5-13
Additional Inpatient Hospital Documentation
Standards 5-13
Serious Reportable Events/Occurrences 5-13
Mass General Brigham Health Plan—Provider Manual 5 –Quality Management Program
5-1 2024-05-01
Section 5: Quality management
program
Overview
Mass General Brigham Health Plan is committed to
improving the quality and safety of care and services
to its patients. This commitment is demonstrated
through the maintenance of a comprehensive Quality
Management Program. The program’s goals support
the mission and objectives of Mass General Brigham
Health Plan, relevant state and federal regulations,
Mass General Brigham Health Plan’ contract with
MassHealth, accrediting agency standards (such as
the National Committee on Quality Assurance
[NCQA]), and the Massachusetts Division of
Insurance’s licensure requirements. The intent of the
Quality Management Program is to improve the
quality and safety of clinical care and services
provided to patients and clinicians. It is based on the
fundamentals of quality management: plan, monitor,
improve, and evaluate, and the “Plan-Do-Study-Act”
cycle approach to continuous performance
improvement.
The Quality Management Program ensures a
comprehensive, systematic, coordinated, integrated,
and formal process for continuous assessing,
monitoring, evaluating, and improving the quality of
clinical care and quality of services provided to
members (Use of the term “monitoring” shall refer to
the monitoring, evaluation, and quality improvement
cycle).
Quality monitoring and improvement activities are
oriented around: routine reporting, management,
and analysis of complaints and grievances; specific
quality improvement projects; peer review; and the
implementation and evaluation of the quality
improvement plan.
Quality management and improvement activities
are aimed at creating highly integrated
collaborative partnerships, both internally and
externally, to ensure excellence in care and
service—as well as to establish and share best
practices.
The Advisory Commission on Consumer
Protection and Quality in the healthcare Industry
recommends that all healthcare organizations make it
their explicit purpose to continually reduce the
burden of illness, injury, and disability, and to improve
the health and functioning of the people of the United
States. In Crossing the Quality Chasm: A New Health
System for the 21 Century (Committee on
Quality Health Care in America, Institute in
America, Institute of Medicine, 2001), the Institute of
Medicine called upon all healthcare organizations to
pursue six major aims and that, specifically,
healthcare should possess the following qualities:
• Safety—Avoiding injuries to patients from the care
that is intended to help them.
• Effectiveness—Providing services based on
scientific knowledge to all who could benefit and
refraining from providing services to those not
likely to benefit (avoiding underuse and overuse).
• Patient-centeredness—Providing care that is
respectful of and responsive to individual patient
preferences, needs, and values and ensuring that
patient values guide all clinical decisions.
• Timeliness—Reducing waits and sometimes
harmful delays for both those who receive and
those who give care.
• Efficiency—Avoiding waste, in particular waste of
equipment, supplies, ideas, and energy.
• Equity—Providing care that does not vary in quality
because of personal characteristics such as gender,
ethnicity, geographic location, and socioeconomic
status.
Mass General Brigham Health Plan is committed to
achieving each of these quality aims, and the Quality
Management Program provides the
specifications for that effort. Clinicians are
expected to collaborate with Mass General
Brigham Health Plan in all quality management
efforts including, but not limited to, compliance
with Leapfrog Safety Measures for reducing
hospital injuries and managing serious errors. More
information on these safety standards is available
at: https://leapfroghospitalsurvey.org/
about-the- survey.
Mass General Brigham Health Plan—Provider Manual 5 –Quality Management Program
5-2 2024-05-01
Scope
The scope of the Quality Management Program,
which speaks to each of the major goals, is designed
to continuously monitor, evaluate, and improve the
clinical care and service provided to its patients. The
Quality Management Program is also designed to
support and reflect Mass General Brigham Health
Plan’s commitment to continuous performance
improvement in all aspects of care and services
provided to its members.
The program is continuous, broad-based, and
collaborative, involving all departments, programs,
and staff. The components of the program are
implemented by the actions of the leadership,
directors, clinicians, and support staff that design,
measure, assess and improve their work processes.
Other sources of guidance include input from
patients, external benchmarks, and aggregate data.
The review and evaluation of these components are
coordinated by the Quality Department to
demonstrate that the process is cross functional,
multi- disciplinary, integrated, and effective in
demonstrating improvements in the quality of clinical
care and services provided. The quality management
program includes quality planning, measurement, and
improvement functions. Each area of improvement
focuses on the measurement and assurance of
effective patient centered care.
All quality management and improvement activities
can be viewed as a process, and processes link
together to form a system. The linkage of the
processes enables the focus of quality improvement
to be on the processes in the organization and not on
the individual departments or people. As such, the
organization measures and improves the performance
of important processes in all organizational functions.
Those processes that have the greatest impact on
outcomes and customer satisfaction are given the
highest priority. Quality Management retains
responsibility and oversight for any quality
management function that falls within the scope of
the program and delegated to another entity.
The Quality Management Program maintains a
strong linkage with the Care Management Program,
fostering ongoing and enhanced quality
improvement collaborations and interactions,
including:
• Identifying opportunities to improve care and
service and develop quality improvement
interventions
• Translating quality into measurable terms and using
data to drive improvements
• Identifying and addressing instances of substandard
care including patient safety, member complaints
and sanctioned providers
• Promoting a collaborative approach to performance
improvement that uses the concepts and tools of
Continuous Quality and Performance Improvement
• Measuring and evaluating the effectiveness of
planned interventions in improving care and service
• Tracking the implementation and outcomes of
quality improvement interventions
• Measuring and evaluating the effectiveness and
impact of the enhancement of comprehensive
health management programs in the areas of health
promotion, asthma, diabetes, depression and high-
risk pregnancy on the well-being and quality of life
of our members.
• The care management programs strive to:
• Support the relationship between practitioners and
their patients with a plan of care
• Emphasize prevention of exacerbations and
complications use evidence-based guidelines
• Promote patient empowerment strategies such as
motivational coaching and self- management, and
continuous evaluation of the clinical, social, and
economic outcomes with the aim of improving
overall health
• Maintain a multidisciplinary, continuum-based
approach to health care management that focuses
on populations at risk for selected conditions.
The Quality Management Program encompasses the
entire organization and includes the following
components:
• Evaluation of population-based systems of care
that address the needs of vulnerable patients
Mass General Brigham Health Plan—Provider Manual 5 –Quality Management Program
5-3 2024-05-01
• Access improvements, including provider
availability and cultural competence
• Promotion of compliance with current preventive
health recommendations
• Evaluation of care coordination activities
• Development and approval of clinical guidelines
and standards
• Assessment of member perceptions of healthcare
and service quality
• Member complaints and appeals
• Provider complaints and appeals
• Credentialing of physicians and other providers
• Evaluation of provider performance
• Medical record review
• Policies supporting members’ rights,
responsibilities, and confidentiality
• Assessment of new technology
• Development of a data collection system to
evaluate outcomes of care, services, and
processes
• Risk management activities
• Structure and Quality Management Program
oversight
MassHealth ACO Quality Measures
ACOs are accountable for providing high- value,
cross-continuum care, across a range of measures
that improves member experience, quality, and
outcomes.
MassHealth will regularly evaluate measures and
determine whether measures should be added,
modified, or removed.
MassHealth’s ACO quality measures cover a host of
domains including but not limited to Prevention and
primary care. Chronic disease management.
Substance use disorder and Member experience
surveys
Mass General Brigham Health Plan Board of
Directors
The Mass General Brigham Health Plan Board of
Directors is responsible for the Quality
Improvement Program. The Board delegates
oversight responsibility for quality of care and
services to the Quality Program Committee. This
committee reports directly to the Board.
Day-to-day oversight of the Quality Improvement
Program is the responsibility of the Chief Medical
Officer and Quality leadership.
Quality Program Committee (QPC)
This committee is responsible for the development,
implementation, and oversight of the Quality
Improvement program, including oversight of other
organizational committees involved in Quality
Improvement initiatives.
QPC members include: decision makers who
represent stakeholders within the Quality
Department as well as representatives from other
departments including Clinical Operations, Pharmacy
Operations, Commercial Sales, Regulatory
Affairs/Compliance, the Medicaid Office, and
Behavioral Health. Each member is responsible for
contributing subject matter expertise to ensure a
balanced discussion of Quality Improvement
programs and improvement initiatives. In addition to
internal participants, QPC includes members from
external organizations including Optum and
participating network providers.
Quality Improvement Committee (QIC)
This committee develops, implements, and monitors
the Quality Improvement (QI) program and functions
by ensuring that performance improvement activities
meet the needs of its members to support population
health, and external regulatory requirements.
QIC members include: decision makers who represent
stakeholders within the Quality Department as well as
representatives from other departments including
Clinical Operations, Customer Service, Pharmacy
Operations, Marketing and Behavioral Health. Each
member is responsible for contributing subject matter
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expertise to ensure a balanced discussion of Quality
Improvement programs and improvement initiatives.
Performance Reporting and
Improvement
Provider Profiling System
Mass General Brigham Health Plan shall establish and
maintain a profiling system for all providers rendering
care for Mass General Brigham Health Plan for the
purpose of obtaining and providing detailed
information which includes, but is not limited to:
• Patient satisfaction
• Outcomes
• Access and utilization data for a provider
The provider agrees to cooperate and participate in
such systems in a manner that is conducive to quality
improvement activities.
Reporting
Upon request, primary care sites are provided with
reports outlining their performance in areas including
but not limited to:
• Emergency room utilization
• Preventive Care
• Chronic Disease
• Patient satisfaction*
• Cost and utilization
*Annually, Mass General Brigham Health Plan conducts a survey of
patients’ satisfaction with their primary care site. The survey
focuses on patients’ satisfaction with access to routine and urgent
care, the effectiveness of communication with the practice staff,
and the perceived level of courtesy and respect demonstrated by
reception staff. Practice specific results are subsequently shared
with practice sites.
Clinical Practice Guidelines
Mass General Brigham Health Plan participates in
local and statewide forums to establish uniform
guidelines that all state purchasers, payers and
providers endorse.
Mass General Brigham Health Plan adopts regional
and national clinical practice guidelines from
recognized sources that are:
• Significance to our membership (prevalence of
disease in our population)
• Based on sound scientific evidence or expert
consensus
• Developed with practicing clinicians (local or
national) in the applicable specialty
• Address documented variation in important care
processes and outcomes
Annually, Mass General Brigham Health Plan
establishes external benchmarks for important quality
measures addressed by clinical practice guidelines
and compares its performance relative to these
benchmarks. Mass General Brigham Health Plan also
uses Clinical Practice Guidelines for its Disease
Management Programs. Mass General Brigham
Health Plan selects at least two important aspects of
care from the clinical practice guidelines that relate to
its Disease Management Programs for quality
performance measurement and improvement
activities.
Clinical Practice Guidelines are reviewed by Mass
General Brigham Health Plan’ clinical leadership at
least every two years and/or as regional and national
guidelines change.
Updates to the guidelines are posted on Mass General
Brigham Health Plan’ website,
For a list of clinical practice guidelines currently
endorsed by Mass General Brigham Health Plan,
please visit Provider resources | Mass General
Brigham Health Plan If you do not have access to the
Internet, please contact Provider Service at
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Healthplan[email protected] to request a
copy. Health Care Access Standards
As part of its ongoing quality of care efforts and to
meet regulatory and contractual requirement, Mass
General Brigham Health Plan monitors and reports on
member access to primary care and specialty services.
This is done by the following methods:
Office-based access and availability surveys
administered by Mass General Brigham Health
Plan.
•
to provider office staff
•
Member satisfaction surveys
•
Site-based surveys
•
Consumer Assessment of Health Care Providers and
Systems (CAHPS) surveys
•
Geographic and numerical assessment:
–
Mileage from member’s residence to provider
location
–
Ratio of provider to members
The survey seeks responses to verify a provider’s
compliance with the availability or wait time
access for the following services:
• Emergency services (including all necessary care
coordination with home health, case management,
behavioral health or other providers involved in the
care of member)
• must be provided immediately and be available 24
hours a day, seven days a week
• Primary care
–
Urgent—within 48 hours of the member’s
request
–
Non-urgent, symptomatic—within 10 calendar
days of the request
–
Non-symptomatic—within 45 calendar days
of the request, unless an appointment is
required sooner in order to ensure the
provision of screenings in accordance with
the MassHealth Early and Periodic Screening,
Diagnosis and Treatment and Preventive
Pediatric Healthcare Screening and Diagnosis
Periodicity Schedules.
• Specialty care
–
Urgent—within 48 hours of request
–
Non-urgent, symptomatic—within 30 calendar
days of request
–
Non-symptomatic—within 60 calendar days of
the request
• Behavioral health
–
Emergency and CBHC services (including all
necessary care coordination with home health,
case management, mental health or other
providers involved in the care of member) must
be provided immediately and be available 24
hours a day, seven days a week.
–
For services described in an inpatient or 24-hour
diversionary services discharge plan:
▪
Non–24-hour diversionary services—with-
in two calendar days of discharge
▪
Medication management—Within 14
calendar days of discharge
▪
Other outpatient services—within seven
calendar days of discharge
▪ Intensive care coordination services—with-
in the time frame directed by the
Executive Office of Health and Human
Services.
–
Urgent—within 48 hours of request
–
All other behavioral healthcare—within 14
calendar days
• Children newly placed in the Department of
Children and Family (DCF) custody— For enrollees
newly placed in the care or custody of DCF—
providers must make best efforts to provide a DCF
Health Care Screening within seven calendar days
of receiving a request, and provide an initial
Comprehensive Medical Examination within 30
calendar days of receiving a request unless
otherwise mandated by the MassHealth Early and
Periodic Screening, Diagnosis and Treatment and
Preventive Pediatric Healthcare Screening and
Diagnosis Periodicity Schedules. Providers must
make best efforts to communicate with the child’s
assigned DSS caseworker(s) and when
appropriate, inform them of rendered Mass
General Brigham Health Plan covered services that
support the child’s needs.
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Waiting Room Wait Time
In addition to these access standards, patients should
be seen within a reasonable time after timely arrival.
A reasonable time is defined as within 30 minutes
from the appointment time.
For more details, call Mass General Brigham Health
Plan Provider Service at 855- 444-4647.
Office Site Audits
• Mass General Brigham Health Plan reserves the
right to conduct a site visit for providers whom
grievances have been filed against.
Except in the instance of a Quality-of-Care Site Visit
(see below), a CMS or state review may be
substituted for a Mass General Brigham Health Plan
site visit. If Mass General Brigham Health Plan is using
a state review in lieu of a conducted site visit Mass
General Brigham Health Plan must verify that the
review was completed within the time limits and
meets Mass General Brigham Health Plan’s site visit
standard. In this instance, organizational provider
applicants must provide a copy of the CMS or state
review report performed within the previous 36
months (about 3 years) and a copy of the
organization’s QI (Quality Improvement Plan and
Credentialing Process. Site visits are performed by the
Provider Relations staff or outside consultants and
provide a mechanism for practitioner education and
facilitation of continuous improvement in the
provision of patient care and service. During the site
visit, specific established standards are applied which
are reviewed and approved by Mass General Brigham
Health Plan’ Provider Network Management. Site
visits for potentially high-volume behavioral health
practitioners are conducted by Mass General Brigham
Health Plan’ delegate, Optum, a fully accredited NCQA
managed behavioral healthcare organization.
• Practice sites are assessed against the following
standards:
• Physical accessibility
• Physical appearance
• Adequacy of waiting and examining rooms
• Appointment availability.
Quality-of-Care Site Visits are conducted when three
(3) or more member complaints/grievances are
received, or when the Senior Director, Quality receives
and external or internal complaint about a quality-of-
care concern that is deemed serious based on a
severity rating and/or review by the Credentialing
Committee, a site visit will be conducted by the Senior
Director, Quality, or his/her delegate.
Such complaints include but are not limited to:
• Reported cases of a patient’s concern when the time
spent with the clinician is perceived as inadequate
to have fully addressed the purpose for the specific
visit
• Failure of clinicians to adhere to patient safety
measures (e.g., washing of hands, wearing of
protective gloves, etc.)
• Failure of the practice to ensure a patient’s safety
and confidentiality (e.g., exam rooms not
adequately locked, etc.).
• Sharp containers located within a child’s reach
• Inappropriate disposal of hazardous waste
• Changes in procedures or policies post
• Passing of the initial site visit (e.g., medical records
no longer adequately secured)
A site visit is scheduled within 30 days of the
registered concern, and providers may be asked for a
corrective action plan with continuing follow-up site
visits until all deficiencies have been addressed.
Medical Records Documentation
Standards
To streamline utilization and quality review, medical
records must adhere to nationally accepted standards
for paper and systematic documentation pertaining to
the appropriateness, course and result of
treatments/services and corresponding outcomes. As
part of ongoing monitoring of network practitioners,
Mass General Brigham Health Plan conducts an
annual review of medical records in a random sample
of the network of PCPs and inpatient hospital sites.
These medical record audit results are analyzed, and
providers are notified of their results.
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Documentation of the provision of effective patient
care should contain all relevant information regarding
the patient’s diagnoses and overall health status, up
to and including:
• Patient’s primary language spoken
• Encounter date
• Clinical information/assessments
• Treatment/services provided
• Treatment plans
• Treatment goals and outcomes
• Contacts with the patient’s family, guardians,
and/or significant others
In monitoring adherence to medical records
documentation standards, Mass General Brigham
Health Plan staff conduct medical record audits at
randomly selected primary care sites to review a
sample of medical records.
Medical records are examined for evidence of
compliance with each of the following essential
medical record standards:
• Name, DOB, MR#, PCP identified on record
• History and physicals recorded on record
• Allergies and adverse reactions documented
• Problem list is present and updated
• Medications list is present and updated
• Visit notes contain clinical findings and evaluation
• Preventive services and risk screenings are recorded
• Lab, radiology, and hospital reports are filed
• Advanced directives are discussed with patients 18
years and older
• Behavioral health screening completed at well child
visit
The Mass General Brigham Health Plan reviewer
must be given full access to the randomly selected
medical charts or direct access to an EMR system.
Compliance for each element requires that the
element be present and easily found. The percentage
of compliance is calculated based on the number of
elements passed divided by the total number of
elements.
The following elements also must be updated
regularly. This is verified by checking recent office
visit notes:
• Allergies and adverse reactions, or their absence,
documented
• Problem list is present and updated
• Medications list is present and updated
• Preventive services and risk screenings are
recorded
When recording compliance, the Mass General
Brigham Health Plan reviewers use the
Documentation Standards Review tool. Upon the
completion of the audit, Quality Management staff
analyze the results and develop site- specific reports.
These reports are then delivered to the previously
identified “key contacts” at each PCP or inpatient
hospital site.
Medical Records Documentation Guidelines
In addition to the items referenced above, Mass
General Brigham Health Plan reserves the right to
audit member charts for compliance with all elements
of medical records documentation requirements. The
following guidelines are provided to assist network
providers with ensuring and maintaining compliance
with appropriate medical records documentation.
Advance Directives
All members 18 years of age and older are notified in
writing of their right to execute advance directives.
Members are provided information about their rights
to:
• Make decisions concerning medical care
• Accept or refuse medical or surgical treatment
• Formulate advance directives (e.g., living wills,
durable powers of attorney for health care, or
health care proxy designations)
Participating PCPs are encouraged to discuss Advance
Directives with adult patients and also required to
document results of the discussion in the medical
record. Mass General Brigham Health Plan audits
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practitioners’ medical records for documentation of
education and information about Advance Directives.
Mass General Brigham Health Plan refers members
and providers to the Massachusetts Medical
Society’s website, www.massmed.org, to the
“Patients,” “Patient Education Materials,” and “Health
Care Proxy Information and Forms” sections to obtain
information and forms.
Personal/Biographical Data
Must include, at a minimum and if applicable, full
name, date of birth, sex, marital status, race, primary
language, address, telephone number (home, mobile,
work), employer name, insurance name, insurance ID
number and any disabilities, such as visually and/or
hearing impaired, uses a wheelchair, and other
information.
Two Unique Identifiers
Must be found on each and every page of the medical
record. Examples of identifiers are patient name,
medical record number, Mass General Brigham
Health Plan ID number, and date of birth.
Medical Record Entries
All medical record entries, whether related to a visit
or for other purposes, must be dated and author-
identified (signed). Author identification signature
may be handwritten stamped, unique electronic
identifier or initials. Professional designation
(credentials) should accompany the signature.
Legibility
The medical record must be legible enough for
someone other than the author to understand the
content of each entry.
Allergies/Adverse Reactions
Medication allergies and adverse reactions, or lack
thereof, must be noted in a prominent location in the
chart. Other allergies significant to the member’s
health status should be documented as well. If the
patient has no known allergies and/or history of
adverse reaction, the record should reflect this.
Drugs, Alcohol and Tobacco
Documentation of an assessment for alcohol, tobacco
and illicit drug use must be present for all members
age 12 and older, including seniors. Members age
12−21 must, at a minimum, be assessed at each well
childcare visit.
Patient Medical History
A comprehensive medical history including serious
illnesses, accidents, surgeries/procedures and
relevant family and social history. An appropriate
entry with regards to immunization records should be
noted in the chart. For children and adolescents, past
medical history relates to prenatal care, birth,
surgeries, and childhood illnesses.
Problem List
Significant illnesses and medical conditions (acute,
chronic, active, resolved, physical and mental),
surgeries and relevant family and social history must
be documented on the problem list. Short-term
illnesses (e.g., flu) and “rule out” conditions may be
excluded. This form must be updated at the time a
new significant problem is identified and confirmed.
Immunizations
An immunization record (for children) is up to date
and (for adult) an appropriate history has been made
in the medical record.
Medication List
A medication list must be present in the record that
includes, at a minimum, the name of the prescription
medication, dosage, frequency, and the date
prescribed. Short-term, illness- specific medications
(e.g., antibiotics) need not be included on this list but
should be documented in the notes of any visits that
occur for the duration of the medication therapy.
When a medication is discontinued, this should be
noted on the medication list with the date that the
medication was discontinued. In the absence of a
structured medication list, all medications must be
relisted in each visit note.
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Under- or Over Utilization
There is appropriate notation for under- or over-
utilization of specialty services or
pharmaceuticals.
Visit Note
All visit note entries must contain the following
elements, except where not applicable based on the
nature of the visit: date of visit, purpose of visit,
pertinent history, physical exam, diagnosis, or clinical
impression including under/over utilization of
specialty services or pharmaceuticals, description of
treatment provided including any medical goods or
supplies dispensed or prescribed, plan of care and
author identification. Author identification signature
may be handwritten, stamped, a unique electronic
identifier or initials. Professional designation
(credentials) should accompany the signature. If the
service is performed by someone other than the
provider claiming payment for the service, the
identity, by name and title, of the person who
performed the service must be documented.
Some visits may not require all of the elements of
a visit note. Examples of such visits include, PPD
planting/reading, blood pressure check, flu shot,
and medication counseling.
Standards for each clinical element of the visit, with
examples, are as follows:
• Purpose of visit—Chief complaint; consists of the
patient’s reason for the visit. May quote the
patient directly (e.g., “I have an itchy rash on my
arm,” or “in for a blood pressure check”).
–
Pertinent history—History of the condition
identifying subjective and objective
information pertinent to the reason the
patient presents (e.g., “Pt. complains of a
stuffy nose and dry cough for three days.
Cough is worse at night. Has been taking OTC
cough medicine q 6 hours with no relief. No
fever or sore throat. . .”).
–
Physical exam—Objective and subjective
information, whether positive or negative,
pertinent to the chief complaint (e.g., “Chest
clear to auscultation. Normal breath sounds”).
–
Diagnosis/clinical impression—Working
diagnosis/assessment must be consistent with
findings from history and physical (e.g.,
–
“Otitis media,” “well-controlled
hypertension,” “well child”).
–
Plan of care—Plans for treatment of condition
and/or follow-up care must be consistent
with the diagnosis. Plans should include
instructions to member as appropriate, and
–
notation of when member is expected to
–
return for next visit. (e.g., “amoxicillin t.i.d. x
10 days,” Hct, Pb, dental referral. RTC 1 yr. or
prn.”). Notes and/or encounter forms should
reflect follow-up care, calls, or visits, when
indicated, including the specific time of return
recorded as weeks, months or as needed.
–
Laboratory/radiology/other—Laboratory and
other studies are ordered, as appropriate.
Results/reports of laboratory tests, x-rays and
other studies ordered must be filed in the
medical record initialed by the ordering
practitioner signifying review. The review and
signature cannot be done by someone other
than the ordering practitioner. When the
information is available electronically, there
must be evidence of review by the ordering
practitioner. If a test or study ordered at the
primary care site is performed at another
location, these results must also be filed in
the primary care site’s medical record.
Abnormal reports must be accompanied by a
documented follow-up plan.
–
Consultation referrals—Referrals to
consultants must be appropriate and clearly
documented. Clinical documentation must be
present in the chart, which supports the
decision to refer to a consultant.
Documentation of the referral should include
the name, location and specialty of the
consultant, the reason for the referral, the
date of the referral and, whenever possible,
the date of the scheduled appointment.
• Consultation reports—For each referral, there
must be a corresponding report in the chart for
the consultant, as well as documented
acknowledgement of the report by the provider.
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Results/reports of all consultations must be
initialed by the ordering practitioner signifying
review. The review and signature cannot be done
by someone other than the ordering practitioner.
If the consultant’s findings are abnormal, there
must be documentation in the chart of the follow-
up plan. There must be no evidence of
inappropriate risk to a patient as a result of
diagnostic or therapeutic procedures from
consultations or the provider’s procedures.
• Consultation, laboratory, and imaging reports
filed in the chart are initialed by the practitioner
who ordered them, to signify review (review and
signature by professionals other than the ordering
practitioner do not meet this requirement.) If the
reports are presented electronically or by some
other method, there is also representation of
review by the ordering practitioner. Consultation
and abnormal laboratory and imaging study
results have an explicit notation in the record of
follow-up plans.
• Unresolved problems—Any problems
• identified at a visit that are not resolved during
that visit must be addressed and documented in
subsequent visits.
–
Preventive Screenings—Evidence that
preventive screenings and services were
offered in accordance with the early periodic
screening diagnosis and treatment EPSDT
periodicity schedule for children and
adolescents or, for individuals over the age of
21, in accordance with the provider’s own
guidelines, including the administration of
behavioral health screenings, is present.
–
Advance Directives—Evidence that the
provider attempted to discuss advance
directives with all adult patients is in the
patient’s medical record.
Additional Pediatric Documentation
Standards
The medical records of all Mass General Brigham
Health Plan members under age 21 must reflect
periodic health maintenance visits as defined by the
Massachusetts Quality Health Partners (MHQP)
Pediatric Preventive Health
Guidelines in effect at the time of the visit. Some
health maintenance standards below apply to
pediatric members of all ages while others apply
only to certain ages or are required once over a
specified time frame.
Mass General Brigham Health Plan documentation
requirements include, but are not limited to, the
following (the ages at which each standard applies
will be noted below the definition of each standard,
and will be followed by the documentation
expectation):
Initial/Interval Medical History
For children and adolescents, past medical history
relates to prenatal care, birth, surgeries, and
childhood illnesses. The initial medical history must
contain information about past illnesses, accidents
and surgeries, family medical history, growth and
development history, assessment of immunization
status, assessment of medications and herbal
remedies, psychosocial history, and documentation of
the use of cigarette, alcohol and/or other substances.
The interval history must contain a review of
systems and an assessment of the member’s
physical and emotional history since the last visit.
Comprehensive Physical Exam
Documentation of a complete, unclothed physical
exam, including measurement of height and weight,
must be present. Head circumference should be
measured until age two and documentation of blood
pressure should begin by age three.
Developmental Assessment
The member’s current level of functioning must be
assessed as concisely and objectively as possible in all
the following areas. Documentation such as
“development on target” or “development WNL” is
acceptable.
PHYSICAL
Gross motor, fine motor, and sexual development
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COGNITIVE
Self-help and self-care skills and ability to reason and
solve problems
LANGUAGE
Expression, comprehension, and articulation
PSYCHOSOCIAL
Social integration, peer relationships, psychological
problems, risk-taking behavior, school performance
and family issues. Ask about daycare arrangements
for infants, toddlers, and preschoolers. Follow- up
should be documented, as appropriate, for
developmental delays or problems.
SENSORY SCREENING
Hearing
• Infancy—The results of a formal newborn hearing
screening, administered prior to a newborn’s
discharge from the birthing center or hospital should
be documented in the chart. A gross hearing screening
(e.g., “turns to sound,” “hearing OK”) must be
documented for all members under age three.
Newborns should be assessed before discharge or at
least by 1 month of age. A subjective assessment
should be conducted at all other routine check-ups.
• 1–17 (Early childhood–adolescence)— Conduct
objective hearing screening at ages 4, 5, 6, 8, and 10. A
subjective assessment should be conducted at all
other routine check-ups.
If testing is performed elsewhere (e.g., school), it does
not need to be repeated by the provider, but findings,
including the date of testing, must be documented in
the medical record. Follow- up should be
documented, as appropriate, for abnormal findings.
Vision
• 0–1 (Infancy)—A gross vision screening
(e.g., “follows to midline,” “vision OK”) must be
documented for all members under three. Newborns
should be assessed using corneal light reflex and red
reflex before discharge or at least by 2 weeks of age.
Evaluation of fixation preference, alignment and eye
disease should be conducted by age six months.
• 1–17 (Early Childhood–Adolescence)— Visual acuity
testing should be performed at ages 3, 4, 5, 6, 8, 10,
12, and 15 years.
• Screen for strabismus between ages 3 and 5—A child
must be screened at entry to kindergarten if not
screened during the prior year per Massachusetts
Preschool Vision Screening Protocol.
Dental Assessment/Referral
Documentation of an assessment of dental care must
be present in the chart. For members under age
three, a discussion of fluoride and bottle caries must
be present and for members age three and older,
teeth must be checked for obvious dental problems
and an assessment must be documented as to
whether the member is receiving regular dental care.
Referral to a dentist must be provided to those
members with abnormal findings.
The documentation should include the following:
Standard: 0-1 Age Range:
•
Counsel against bottle-propping when feeding
infants and babies.
•
Counsel against bottles to bed.
•
Assess oral health at each visit and need for fluoride
supplementation at 6 months based upon
availability in water supply and dietary source of
fluoride.
•
Encourage brushing with a soft toothbrush/cloth
and water at age 6 months.
•
Encourage weaning from bottle and drinking from a
cup by the first birthday.
•
Apply fluoride varnish to primary teeth of all infants
and children every 6 months if not applied at dental
home and every 3 months if at high risk for caries.
Standard 1-21 Age Range:
• Apply fluoride varnish to primary teeth for all
children aged 1-5 every 6 months if not applied at
dental home and every 3 months if at high risk for
caries.
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• Assess oral health at each visit and need for fluoride
supplementation up to age 14 based on availability
in water supply and dietary source of fluoride.
• Counsel on good dental hygiene habits, including
brushing twice daily.
• Counsel on the establishment of a dental home
beginning at 12 months or after eruption of first
tooth.
• Counsel on use of mouth guards when playing
sports.
Health Education/Anticipatory Guidance
Age-appropriate assessment, discussion and
education relating to physical, developmental,
psychosocial, safety and other issues must be
documented at each well childcare visit.
Immunization Assessment/Administration
Updated documentation of assessment of
immunization status, and administration of
immunizations according to most current Department
of Public Health (DPH) guidelines, must be present in
the chart on an immunization flow sheet. For
immunizations administered, the documentation
must include, at a minimum, the name of the
immunization, the initials of the person who
administered the vaccine and the date administered.
It is recommended that lot number also be
documented. For immunization records received from
prior providers, including the hepatitis B #1 received
in the hospital at birth, review by the provider must
be explicitly documented.
“Immunizations up-to-date” is not adequate
documentation to indicate review. For hepatitis B
immunizations received at birth, the name of the
hospital and the date administered must also be
documented.
Exposure to Lead Risk Assessment
0–10 (INFANCY–MID-CHILDHOOD)
There must be documented evidence that the
provider assessed the member for exposure to lead
according to the following schedule:
• Initial screening between 9–12 months of age
• Annually at 2 and 3 years of age
• At age 4 if the child lives in a city/town with high risk
for childhood lead poisoning
• At entry to kindergarten if not screened before
Documentation that the member is either “high” or
“low” risk is acceptable. For members documented as
“high risk,” results of a blood lead test must be
present in the chart.
Tuberculin Test
0–21 (infancy–young adult) Tuberculin skin testing for
all patients at high risk. Risk factors include having
spent time with someone with known or suspected
TB; coming from a country where TB is quite
common; having HIV infection; having injected illicit
drugs; living in the U.S. where TB is more common
(e.g., shelters, migrant farm camps, prisons); or
spending time with others with these risk factors.
Documentation of a reading of the results by a
clinician must be present and dated 48−72 hours after
testing. Determine the need for repeat skin testing by
the likelihood of continued exposure to infectious TB.
Early and Periodic Screening and Diagnostic
Testing (EPSDT)
Primary care providers (PCPs) caring for Mass General
Brigham Health Plan MassHealth members under age
21 must offer to conduct periodic and medically
necessary inter- periodic screens as defined by
Appendix W of MassHealth’s Early and Periodic
Screening, Diagnosis and Treatment (EPSDT) and
Preventive Pediatric Healthcare Screening and
Diagnosis (PPHSD) Periodicity Schedules. For more
information, please see the Behavioral Health
Provider Manual.
Other Testing
There should be documentation for other screening
tests as appropriate to the member’s risk and the
provider’s judgment. At a minimum, the date and
results of the test must be documented.
Additional Inpatient Hospital Documentation
Standards
• Member identification
• Admission date
Mass General Brigham Health Plan—Provider Manual 5 –Quality Management Program
5-13 2024-05-01
• Dates of application for and authorization of Mass
Health benefits, if applicable
• Emergency admission justification, if applicable
• Dates of operating room use, if applicable
• Dates of initial and continued stay review
• Physician Name
• Plan of care
• Reason and plan for continued stay
In accordance with Mass General Brigham Health Plan
Member Rights and Responsibilities, members have
the right to ask for and receive a copy of their medical
record and request that it be changed or corrected.
Serious Reportable
Events/Occurrences
A serious reportable event (SRE) is an event that
occurs on the premises of a provider’s site that results
in an adverse patient outcome, is identifiable and
measurable, has been identified to be in a class of
events that are usually or reasonably preventable,
and is of a nature such that the risk of occurrence is
significantly influenced by the policies and procedures
of the provider.
Potential SREs or quality of care (QOC) occurrences
may be identified by members, providers, or Mass
General Brigham Health Plan staff and may come
into Mass General Brigham Health Plan through
Mass General Brigham Health Plan Customer
Service or any other department. The duty to
report a SRE is the responsibility of the individual
facility or provider. The facility or provider must
document their findings and provide a copy of the
report to both DPH and the Mass General Brigham
Health Plan Clinical Review Specialist Patient Safety
Nurse within the required time frame.
Issues of concern may also be found through claims
data or when medical record audits are performed by
Mass General Brigham Health Plan. Claims data are
reviewed on a monthly basis to identify possible SREs.
Any problems identified include both acts of
commission and omission, deficiencies in the clinical
quality of care, inappropriate behavior during the
utilization management process, and any instances of
provider impairment documented to be a result of
substance abuse or behavioral health issues. All
contracted providers must participate in and comply
with programs implemented by the Commonwealth
of Massachusetts through its agencies, such as, but
not limited to the Executive Office of Health and
Human Services (EOHHS), to identify, report, analyze
and prevent SREs, and to notify Mass General
Brigham Health Plan of any SRE.
Mass General Brigham Health Plan promptly reviews
and responds within 30 days to actual or potential
QOC occurrences. The provider will have thirty days
to submit the required DPH SRE reports to the Plan
Mass General Brigham Health Plan uses the National
Quality Forum’s (NQF) definition of SREs and the
NQF’s current listing of “never events.”
Mass General Brigham Health Plan does not
reimburse services associated with SREs that are
determined to be preventable after a root cause
analysis (RCA) has been completed. To administer this
policy, Mass General Brigham Health Plan recognizes
but is not limited to the SREs identified by the
National Quality Forum, Healthy Mass, and the CMS
Medicare Hospital Acquired Conditions and Present
on Admission indicator reporting. This policy applies
to all hospitals and sites covered by their hospital
license, ambulatory surgery centers, and providers
performing the billable procedure(s) during which an
“event” occurred.
Mass General Brigham Health Plan will reimburse
eligible providers who accept transferred patients
previously injured by an SRE at another institution
(facility) or under the care of another provider.
Mass General Brigham Health Plan—Provider Manual 6 –Clinical Programs and Utilization Management
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Section 6: Clinical programs and utilization management
Mass General Brigham Health Plan
Care Management Program 6-1
Mass General Brigham Health Plan
Care Teams 6-1
Mass General Brigham Health Plan
Care Management Services 6-1
Additional Care Management Services 6-1
Mass General Brigham Health Plan
Utilization Management 6-2
Requesting and Obtaining an
Authorization or Referral 6-2
Submission through the Provider Portal 6-2
Valid Prior Authorization Requests 6-3
Confirmation of Requested Authorizations 6-3
Utilization Management Methods 6-3
Referrals 6-3
Prior Authorization (Prospective Review) 6-4
Durable Medical Equipment (DME) 6-4
Enteral Products 6-5
Prior Authorization Requests Submitted
Directly to a Delegated Entity 6-5
Concurrent Review 6-6
Retrospective Review 6-6
UM Time Frame for Decision-Making
and Notification 6-7
UM Time Frame for Decision-Making
and Notification 6-8
Notification 6-10
Notification of Birth Process 6-10
Out-of-Network Requests 6-11
Discharge Planning 6-11
Medical Necessity Decision-Making 6-12
Collection of Clinical Information for UM
Decision-making 6-12
Clinical Criteria 6-12
MassHealth’s Definition of Medical Necessity 6-13
Information Request 6-13
Medical Necessity Denials 6-13
Discharge Planning to Support Members
Experiencing or at Risk of Homelessness 6-13
Administrative Denials 6-14
Delegation of Utilization Management 6-14
Online Clinical Reports on the Provider
Portal 6-15
Nurse Advice Line 6-15
Mass General Brigham Health Plan—Provider Manual 6 –Clinical Programs and Utilization Management
6-1 2024-05-01
Section 6: Clinical programs and
utilization management
Mass General Brigham Health Plan
Care Management Program
Mass General Brigham Health Plan is dedicated to
providing well- managed patient-centered care to
Mass General Brigham ACO members. For optimal
coordinated care, Mass General Brigham ACO
members should always be referred within the Mass
General Brigham ACO network.
The Mass General Brigham Health Plan Care
management program primarily serves members
identified as high-risk and rising risk. Interventions are
tailored to meet members where they are with
increased services being made available to those with
complex, costly, and/or chronic needs.
The care management program combines local, in-
person care management at the points of care and
in the community with remote, health-plan-based,
telephonic Care Management. As appropriate,
services may be delivered in the member’s home.
With this well-coordinated and patient- centered
model, the care management program promotes
high-quality and efficient care delivery. The program
is intended to help reduce avoidable readmission and
ED utilization, while improving member health
outcomes and satisfaction.
Mass General Brigham Health Plan
Care Teams
Integrated and multidisciplinary care teams are
available to members across all Mass General
Brigham ACO practices. These collaborative teams will
include cross-organizational clinical staff and primarily
serve those that are identified as high risk or rising
risk patients. With this collaborative model, this
program expects to: • Deliver stronger care
coordination
• Improve communication with patient and within
care team
• Improve patient outcomes
• Reduce duplicative spending and services
• Develop and strengthen community physician
relations
• Improve quality of care
• Improve patient satisfaction and engagement
• Ensure that the patient has access to the right
care at the right time
Mass General Brigham Health Plan
Care Management Services
High-risk and rising-risk patients enrolled in
Mass General Brigham Health Plan’s Care
Management Program are eligible to receive the
following services as appropriate based on individual
patient needs and goals:
• Comprehensive Assessments (if Care Needs
• Screening indicates the member has a
• Special Health Care Need)
• Development of patient-centered Care Plans
• Referrals to specialty and disease management
programs as appropriate
• Referrals to LTSS and BH CPs as needed and
appropriate
• Home visits
• Face-to-face and/or telephonic Care Management
• Care Management focused on improving health
outcomes, reducing inappropriate utilization of
resources, and ensuring communication and
collaboration across the care continuum.
• Assistance when appropriate with improving
Social Determinants of Health (SDOH) as they
relate to and affect the members’ health status
• Disease management
• Wellness programs
• Transitions of care management
• Medication reconciliation and medication
education
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Mass General Brigham Health Plan
Utilization Management
The Utilization Management (UM) program is
designed to ensure the provision of the highest
quality of health care to Mass General Brigham ACO
members while at the same time promoting
appropriate, efficient, and cost-effective resource
utilization. As such, the UM program focuses on:
• Evaluating requests for services by determining
the medical necessity, appropriateness, and
effectiveness of the requested services
• Promoting continuity of patient care through the
facilitation and coordination of patient services to
ensure a smooth transition for members across
the continuum of health care
• Analyzing utilization statistics to identify trends
and opportunities for improvement
• Reviewing, revising, and developing medical
coverage policies to ensure that utilization
management criteria are objective and based on
medical evidence and that Mass General Brigham
ACO patients have appropriate access to new and
emerging efficacious technologies.
Referrals, prior authorization, notification,
concurrent review, retrospective review, and
discharge planning are all elements of the
utilization management program.
As underutilization of medically appropriate services
has the potential to adversely affect patients’ health
and wellness, Mass General Brigham Health Plan
promotes appropriate utilization of services.
Utilization management decisions are based on
appropriateness of care and service and the existence
of coverage. Mass General Brigham Health Plan does
not specifically reward practitioners or other
individuals conducting utilization review for issuing
denials of coverage or service, nor does Mass General
Brigham Health Plan provide financial incentives to
UM decision makers to encourage decisions that
result in underutilization.
The treating provider, in conjunction with the
member or designee, is responsible for making all
clinical decisions regarding the care and treatment
of the member. Mass General Brigham Health Plan
clinicians are responsible for making all utilization
decisions in accordance with the patient’s plan of
covered benefits and established medical necessity
criteria.
Mass General Brigham Health Plan network providers
are contractually prohibited from holding any Mass
General Brigham ACO member financially liable for
any service administratively denied by Mass General
Brigham Health Plan for the failure of the provider to
obtain the required prior authorization or
notification for the service, or for services denied
because the provider failed to submit supporting
clinical documentation with their request.
Mass General Brigham Health Plan periodically
reviews the services for which prior authorization is
required as practice patterns in the network warrant.
Providers are notified of changes via the eNewsletter,
the provider portal, and/or written communications.
Requesting and Obtaining an Authorization or
Referral
Referrals for MGB ACO members are not required for
in-network providers. Prior authorization and
notification requirements for general services are
available on Providers | Mass General Brigham Health
Plan.
Most Surgical Day Care (SDC) services do not require
authorization. A consolidated list of SDC procedures
requiring authorization can be found on Providers |
Mass General Brigham Health Plan.
Not all DME and orthotics require authorization. See
the Prior Authorization Exemptions for DME, Orthotic
and Prosthetics list on Providers | Mass General
Brigham Health Plan.
Submission through the Provider Portal
Required referrals, authorizations and notifications
must be submitted through Mass General Brigham
Health Plan online authorization tool, accessed
through the provider portal, Mass General Brigham
Health Plan Provider Portal . Clinical documentation
Mass General Brigham Health Plan—Provider Manual 6 –Clinical Programs and Utilization Management
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to support authorization requests can also be
submitted via the provider portal. To expedite
decision making, complete clinical information
supporting medical necessity should be uploaded
with the request on the Mass General Brigham Health
Plan Provider Portal .
Authorization or referral requests to a non- Mass
General Brigham Health Plan network provider
cannot be submitted through the provider portal and
requires fax submission:
Fax 617-586-1700
Valid Prior Authorization Requests
A valid prior authorization request is defined as one
where:
• The request is initiated by the primary care
provider (PCP), treating specialist, or the treating
provider.
• The patient is actively enrolled with Mass General
Brigham Health Plan Mass General Brigham
Health Plan at the time of the service.
• The appropriate authorization template is
completed for those service requests that require
submission through the Mass General Brigham
Health Plan Provider Portal.
• The appropriate authorization form is completed
for service requests that are still faxed or mailed.
• A physician prescription is included with a request
for enteral formulas, infusion therapy and DME.
• Clinical documentation to support medical
necessity is included.
Confirmation of Requested Authorizations
Mass General Brigham Health Plan providers obtain
confirmation of received authorization requests and
UM decision-making from the Mass General Brigham
Health Plan Provider Portal including the
authorization identification number, authorization
decision, number of days/visits, and the duration
approved or denied. Authorization reports specific to
a member, individual authorization, or an aggregate
of all requests made by the servicing provider are
available through the provider portal.
Only those requests made by the requesting
servicing provider may be viewed by the
requesting servicing provider.
Existence of an authorization identification number
does not ensure that a request has been approved. All
requests are assigned an authorization identification
number for tracking purposes independent of the
approval status. It is imperative that providers validate
the status of a specific authorization request.
The Service Authorization Report informs the provider
that a request was either:
• Approved (A) based on medical necessity, benefit
coverage and member eligibility,
• Closed (C) due to a change in level of care (i.e., an
observation stay that escalates to an inpatient
admission) or administrative error,
• Denied (D) based on medical necessity or
administrative guidelines, or
• Pended (P) awaiting clinical review or more
information.
• Medreview (M) awaiting clinical review or more
information.
All authorization decisions resulting in an adverse
determination are also communicated to the
requesting provider by phone and in writing.
Utilization Management Methods
Referrals
Mass General Brigham Health Plan promotes a health
care delivery model that supports PCP coordination
and oversight of care. Mass General Brigham Health
Plan recognizes that its members are best served
when there is coordination between specialty and
primary care clinicians. Referrals are not required to
specialists within the Mass General Brigham Health
Plan ACO network.
To ensure reimbursement, care provided by a non-
Mass General Brigham Health Plan ACO network
specialist may require a referral from the PCP. The
Mass General Brigham Health Plan PCP is the only
provider authorized to make referrals to specialists.
The PCP should submit the referral before the initial
recommended specialty visit and no later than 90
days after the initial specialty visit. Without the
required referrals, payment is subject to denial.
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Some services such as family planning, gynecologist,
or obstetrician for routine, preventive, or urgent care,
behavioral health services, and emergency services do
not require a referral.
Prior Authorization (Prospective Review)
Prior authorization allows for the efficient use of
covered health care services and helps to ensure that
members receive the most appropriate level of care in
the most appropriate setting.
Mass General Brigham Health Plan identifies certain
services as requiring prior medical necessity review
and approval subsequent to meeting established
criteria. Prior authorization processes support care
management involvement by connecting the
Utilization Management Care Manager with the
provider and member prior to the delivery of services.
Certain requested services, procedures, or admissions
require prior authorization. Prior authorizations are
based on medical necessity and are not a guarantee
of payment. Requests for services requiring prior
authorization must be submitted prior to delivery of
service. Failure to obtain required prior authorization
can result in a denial of payment to the provider.
For elective services, such as admissions and surgical
day, Mass General Brigham Health Plan requires at a
minimum, submission five business days prior to the
admission. Authorization determinations for elective
services can take up to 14 calendar days to ensure
adequate time for review and processing (See “UM
Time Frame for Decision-making and Notification”).
Prior authorization is not required for:
• Emergency room care
• Observation
• Emergent acute inpatient admissions.
Requests for prior authorization services are
forwarded to a Utilization Management Care
Manager for review. The Utilization Management
Care Manager will determine whether the requested
service meets established review criteria guidelines.
The Utilization Management Care Manager will
contact the servicing provider or PCP whenever there
is a question regarding the requested type of service
or setting. Additional clinical information may be
required in order to make a medical necessity
decision.
Prior authorization approvals are made by Mass
General Brigham Health Plan Utilization Management
Care Managers based on medical necessity criteria.
Prior authorization denials (adverse determination)
for medical necessity are made only by the Deputy
Chief Medical Officer, a Mass General Brigham
Health Plan Medical Director, or a designated
physician reviewer, based upon medical necessity
criteria, the specific needs of the individual member
and the availability of local resources.
Durable Medical Equipment (DME)
DME purchases and rentals must be requested
by the patient’s PCP, treating provider, or an
approved vendor.
Some DME items are not subject to authorization
requirements. For a list of services that require prior
authorization, please review the DME Prior
Authorization list on the provider portal. This list also
includes medical supplies, oxygen related equipment,
orthotics and prosthetics that require prior
authorization.
DME prior authorization requests are submitted
through Mass General Brigham Health Plan Provider
Portal. The physician’s prescription and supportive
documentation for the requested DME must be
attached to the electronic request. A valid
authorization request, supportive documentation,
and a physician’s prescription are required before a
requested service can be approved.
Providers need to submit requests including
supporting information and a prescription directly
to the participating vendor. Mass General Brigham
Health Plan staff works directly with the vendors to
insure efficient and timely filling of requests.
Enteral Products
Authorization requests for enteral products are
submitted through Providers | Mass General
Brigham Health Plan. A valid authorization request
and completed Combined MassHealth Managed
Care Organization (MCO) Medical Necessity
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Review Form for Enteral Nutrition Products (special
formula) form indicating the specific product and
quantity are required before a determination can
be made to approve a requested service.
Prior Authorization Requests Submitted
Directly to a Delegated Entity
eviCore Healthcare
The following elective outpatient services require prior
authorization through eviCore Healthcare Selected
Molecular & Genetic Testing.
The medical services that may be reviewed include
inpatient services, select inpatient and outpatient
surgical procedures and select imaging and ancillary
services.
When these services are rendered as part of a hospital
emergency room, observation stay, surgical care or
inpatient stay, they are not subject to prior
authorization requirements. Submit requests directly
to eviCore by:
• Accessing online services at www.evicore.com. After
a quick and easy one-time registration, you can
initiate a request, check status, review guidelines,
and more.
• Calling eviCore toll-free, 8 AM to 9 PM ET
at: 888-693-3211
Once approved, an authorization number is faxed to
the ordering/referring practitioner and the
rendering/performing provider. eviCore approves by
the specific facility performing the study and by the
specific CPT code(s). It is the responsibility of the
rendering/performing facility to confirm that they are
the approved facility for rendering the service and the
specific study authorized by CPT code. Any change in
the authorized study or provider requires a new
authorization. Failure to obtain authorization or
submit supporting documentation to establish
medical necessity could result in an administrative
denial of services to the provider.
Sleep Studies and Therapy Management
Mass General Brigham Health Plan partners with
CareCentrix, Inc. (CCX) to provide sleep study and
therapy management services. Testing may be
approved in the patient's home, using a Home Sleep
Test (HST) or in an in-network sleep lab using a
polysomnogram.
Submit requests directly to CareCentrix by:
• Visiting the CareCentrix website
https://www.carecentrixportal.com and
accessing the secure Sleep Portal to submit the
request.
• Phoning CareCentrix, Monday through Friday,
8AM to 5:00 PM, EST, at: (886)-827-5861
For information on billable codes, access
Mass General Brigham Health Plan’s Provider
Payment Guideline for Sleep Studies and Therapy
Management. Criteria for medical necessity
decision making is available on the Mass General
Brigham Health Plan Provider Portal.
Behavioral Health Services
Mass General Brigham Health Plan partners with
Optum to manage the delivery of behavioral
health services for all Mass General Brigham ACO
patients. For more information, contact Optum at
844-451- 3519.
Concurrent Review
Concurrent review is required for subsequent days of
care or visits or services beyond the initial
authorization or required notification. Concurrent
review must be conducted via the Mass General
Brigham Health Plan Provider Portal where indicated.
For services that cannot be conducted via the
Provider Portal, you may fax or mail. Most requests
for concurrent services are submitted through the
provider portal. Follow the provider portal User Guide
for revising authorizations. Those service requests
that are not accepted through the provider portal
must be faxed or mailed to Mass General Brigham
Health Plan. All concurrent requests must be
supported by clinical documentation to determine
medical necessity. Failure to obtain authorization or
submit supporting documentation to establish
medical necessity could result in an administrative
denial of services to the provider.
Concurrent review includes utilization management,
discharge planning, and quality of care activities that
take place during an inpatient stay, an ongoing
outpatient course of treatment or ongoing home care
course of treatment (for example, acute hospital,
skilled nursing facilities, skilled home care, and
continuous DME supplies/equipment).
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The concurrent review process also includes:
• Collecting relevant clinical information by chart
review, assignment of certified days and
estimated length of stay, application of
professionally developed medical necessity
criteria, assignment of level of care, and benefit
review. These criteria are not absolute and are
used in conjunction with an assessment of the
needs of the member and the availability of local
health care resources.
• Obtaining a request from the appropriate facility
staff, practitioners, or providers for authorization
of services.
• Reviewing relevant clinical information to support
the medical necessity.
• Determining benefit coverage for authorization of
service
• Communication with the health care team
involved in the member’s care, the member
and/or his or her representative and the provider
• Notifying facility staff, practitioners, and providers
of coverage determinations in the appropriate
manner and time frame
• Identifying discharge planning needs and
facilitating timely discharge planning.
• Identifying and referring potential quality of care
concerns, Never Events/Serious Reportable Events
and Hospital Acquired Conditions for additional
review
• Identifying members for referral to Mass General
Brigham Health Plan’s Care Management specialty
programs
All existing services will be continued without
liability to the member until the member has been
notified of an adverse determination. However,
denial of payment to the facility and/or attending
physician may be made when days of care or visits
do not support medically necessary care.
Retrospective Review
As part of Mass General Brigham Health Plan’s UM
program in assessing overutilization and
underutilization of services, focused retrospective
review activity may be performed as cost drivers,
HEDIS scores, changes in medical and pharmacy
utilization trends, provider profiling and financial
audits suggest.
Retrospective review is also performed on a case-
by-case basis and is routinely applied to hi-tech
radiology cases.
In the event that the Utilization Management Care
Manager is unable to perform concurrent review,
cases may be reviewed retrospectively. A copy of
the medical record will be requested in accordance
with applicable confidentiality requirements
UM Time Frame for Decision- Making
and Notification
Authorizations are made as expeditiously as
possible, but no later than within the designated
time frames below.
MassHealth members do not receive written
notification of prior authorization or concurrent
authorization approvals.
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UM Time Frame for Decision-Making and Notification
UM Subset
Decision Time Frame
Verbal
Notification
Provider
Written/Electronic
Provider
Approval
Notification
Written Denial
Notification
Pre-service/Initial
Determination
Non-urgent
Standard
Within 14 calendar
days after receipt of
the request the
member or
authorized
representative may
request an extension
for up to 14
additional calendar
days
Denial
Within 14 calendar
days after receipt of
the request
Electronic
notification is
available on the next
business day after
the decision
determination and
within 14 calendar
days after receipt of
the request
Within 14 calendar
days after receipt of
the request
Pre-service/Initial
Determination
Urgent/Expedited
Up to 72 hours/three
calendar days of
receipt of the request
the member or
authorized
representative may
request an extension
for up to 14 additional
calendar days
Denial
Within 72
hours/three
calendar day of
receipt of request
Electronic
notification is
available on the next
business day after
the decision
determination and
within three
business days
after receipt of the
request
Within 72
hours/three
calendar days of
verbal notification
and not to exceed
three business days
from receipt of
receipt of the
request
Concurrent
Review
Urgent/Expedited
Inpatient stays are
always considered
Urgent/Expedited
Within 24 hours/one
calendar day of
receipt of the
request.
The member or
authorized
representative may
request an extension
for up to 14
additional calendar
days
Denial Within 24
hours/one calendar
day of receipt of
request
Approval
Within 24 hours/1
calendar day of
receipt of request
Electronic notification
is available on the
next business after
the decision
determination and
within three
business days
after receipt of
the request
Within 72
hours/three
calendar days of
verbal notification
and not to exceed 3
business days from
receipt of request
exceed three
business days from
receipt of request
Service is continued
Service is continued
without liability to
member until
notification
Continues on next page
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Notification of Birth Process (NOB)
• Babies will no longer be automatically
assigned to their mother’s plan. Plan assignments
for newborns are now prospective. MassHealth
no longer assigns plans retroactively to date of
birth. There are two new fields on the NOB so the
family can select the baby’s PCP and plan when
the NOB is completed in the hospital
• Hospitals will be required to notify MassHealth
within 10 days of a baby’s birth whenever
possible. However, you will no longer be required
to notify Mass General Brigham Health Plan.
• The family can also enroll the newborn in a health
plan by visiting MassHealthchoices.com or calling
MassHealth customer service at 800-841-2900,
Monday-Friday 8 am – 5 pm.
• Babies will be enrolled in MassHealth fee-for
service until MassHealth receives the NOB and
assigns a plan. If the family does not enroll the
newborn in a plan either on the NOB or within 14
days of NOB submission, MassHealth will
automatically assign the newborn into a managed
care plan.
• To determine eligibility and plan information,
hospitals should check the MassHealth electronic
verification system daily.
For further details please refer to the
MassHealth All Provider Bulletin 305 Policies and
Procedures for Newborn Members Dec 2020
Changes for Sick Newborns
For sick newborns, submit authorizations under the
baby’s ID once the baby is enrolled in Mass General
Brigham Health Plan. When eligibility has been
established, you must submit a prior approval request
to Mass General Brigham Health Plan within 24 hours.
Notification of the admission should be submitted by
the hospital.
UM Subset
Decision Time Frame
Verbal
Notification
Provider
Written/Electronic
Provider
Approval
Notification
Written Denial
Notification
Concurrent
Non-urgent/
Standard
Within 14 calendar
days after receipt of
the request.
The member or
authorized
representative may
request an extension
for up to 14
additional calendar
days
Denial
Within 14 calendar
days after receipt of
the request
Approval
Within 14 calendar
days of receipt of the
request
Electronic
notification is
available on the next
business day after
the decision
determination and
within 14 calendar
days after receipt of
the request
Within 1 business day
following verbal
notification, but no
later than 14 calendar
days after receipt of
the request
Reconsideration of
Adverse
Determination
(Initial and concurrent
medical necessity
review determination)
Within one business
day of receipt of
request for
reconsideration
Within one business
day of receipt of
request for
reconsideration
According to type of
request as described
above
According to type of
request as
described above
For termination,
suspension, or
reduction of a
previous
authorization
N/A
N/A
N/A
At least 10 calendar
days prior to date of
action
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Out-of-Network Requests
Mass General Brigham Health Plan PCPs should
always refer members within the Mass General
Brigham Health Plan MGBACO network. Should the
PCP refer a member outside the Mass General
Brigham Health Plan network, the PCP must obtain
the applicable referral and prior authorizations to
confirm coverage.
Authorization is required for all non-emergent out-of-
network service requests except for early intervention
services, and family planning services provided to
Mass General Brigham ACO members. Mass General
Brigham ACO members may obtain family planning
services at any MassHealth family service planning
provider, even if the provider is out of the Mass
General Brigham Health Plan network.
Mass General Brigham Health Plan providers can be
found in the Provider Directory.
Mass General Brigham Health Plan works with
members and clinicians to provide continuity of
care and to ensure uninterrupted access to
medically necessary covered services, whether
current patients or newly enrolled.
In most cases, a pre-existing relationship with an out-
of-network provider is not reason alone to justify the
need for an out-of-network provider.
Requests for services by an out-of-network provider
are submitted electronically via a web portal Mass
General Brigham Health Plan Provider Portal and are
subject to medical necessity review.
Discharge Planning
Discharge planning occurs through the entire
continuum of care for members engaged in medical
as well as behavioral health treatments since
members are discharged from home care and
outpatient service, as well as inpatient stays more
commonly associated with discharge planning.
Discharge planning for Mass General Brigham ACO
members is initiated as expeditiously as possible on
admission to the inpatient facility and with the
initiation of home and outpatient services and is
addressed through- out the continuum of care to
facilitate timely and appropriate discharge and post-
discharge services.
Utilization Management Care Managers ensure that
treating providers have up-to date benefit
information, understand the member’s benefit plan,
possible barriers with authorizing transition services,
and know how to access covered. Discharge planning
transcends the care setting, and therefore, all
Utilization Management Care Managers are required
to be proficient in all operations that encompass
discharge planning, including a full understand of
community resources available to the member.
Utilization Management Care Managers arrange for
in-network services and out-of- network
authorizations when the network of providers cannot
meet the members after care needs. In addition to
assisting the provider with traditional
authorization/benefit information, the Utilization
Management Care Manager collaborates and
coordinates services with the provider and works
with other appropriate members of the health care
team, including but limited to, Mass General Brigham
Health Plan care management programs, behavioral
health care management programs, community and
agency resources and the patient’s designee on their
unique discharge planning needs in order to
coordinate services and facilitate a smooth transfer
of the patient to the appropriate level of care and/ or
into clinical care management programs that will
continue to support the patient’s recovery.
Discharge Planning to Support Members
Experiencing or at Risk of Homelessness
MassHealth has established specific discharge
planning requirements for Acute Inpatient Hospitals,
Freestanding Psychiatric Hospitals and Accountable
Partnership Plans. These requirements were put in
place to create more effective discharge planning
efforts in order to decrease the number of people who
are discharged from healthcare facilities directly to
homeless shelters.
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For additional information on MassHealth
requirements can be found at MassHealth Managed
Care Entity Bulletin 64 July 2021
As required, please notify us to initiate a member’s
discharge planning process at: massbhcca@
optum.com (behavioral health), or
massheal[email protected] (medical)
Please provide the following member information in
your email: patient’s full name, date of birth, referring
facility name, facility discharge specialist name, phone
number and email.
Medical Necessity Decision-Making
Underutilization of medically appropriate services has
the potential to adversely affect our members’ health
and wellness. For this reason, Mass General Brigham
Health Plan promotes appropriate utilization of
services. Mass General Brigham Health Plan’s
utilization management decisions are based only on
appropriateness of care and service and existence of
coverage. Mass General Brigham Health Plan does not
arbitrarily deny or reduce the amount, duration, or
scope of a covered service solely because of the
diagnosis, type of illness, or condition of the patient
or make authorization determinations solely on
diagnosis, type of illness or the condition of the
patient.
All medical necessity decisions are made only after
careful consideration of the applicable written
medical criteria, interpreted in light of the individual
needs of the member and the unique characteristics
of the situation.
Mass General Brigham Health Plan does not
specifically reward practitioners or other individuals
conducting utilization review for issuing denials of
coverage or service, nor does Mass General Brigham
Health Plan provide financial incentives to UM
decision- makers to encourage decisions that result in
underutilization.
In all instances of medical necessity denials, it is
Mass General Brigham Health Plan’s policy to
provide the treating/referring practitioner with an
opportunity to discuss a potential denial decision
with the appropriate practitioner.
Collection of Clinical Information for UM
Decision-making
The Mass General Brigham Health Plan clinical
operations staff requests only that clinical information
which is relevant and necessary for decision-making.
Mass General Brigham Health Plan uses relevant
clinical information and consults with appropriate
health care providers when making a medical
necessity decision.
When the provided clinical information does not
support an authorization for medical necessity
coverage, the care manager and/or physician
reviewer outreaches to the treating provider for
case discussion. A decision will be made based on
the available information if the treating provider
does not respond within the time frame specified.
All clinical information is collected in accordance
with applicable federal and state regulations
regarding the confidentiality of medical
information.
Under the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), Mass General
Brigham Health Plan is entitled to request and
receive protected health information for
purposes of treatment, payment, and health care
operations without the authorization of the
patient.
Clinical Criteria
Mass General Brigham Health Plan internally
develops and uses medical necessity guidelines and
criteria to review medical appropriateness of
targeted services based on its member population
and service utilization. Utilization management
criteria and procedures for their application are
reviewed at least annually and guidelines and criteria
are updated when appropriate.
Mass General Brigham Health Plan uses Change
Healthcare’s InterQual criteria tools or the Mass
General Brigham Health Plan Medical Necessity
Guidelines on massgeneralbrighamhealthplan.org to
Mass General Brigham Health Plan—Provider Manual 6 –Clinical Programs and Utilization Management
6-11 2024-05-01
make decisions for authorization or requested
services or treatment.
Guidelines and criteria internally developed are
reviewed at least annually and criteria are updated,
when appropriate, by Mass General Brigham Health
Plan clinicians under the direction of the Deputy Chief
Medical Officer and Medical Directors. Development
and review of guidelines/criteria under Mass General
Brigham Health Plan’s Pharmacy Program occur
through Mass General Brigham Health Plan’s’
Pharmacy and Therapeutics Committee. Development,
review, and application of medical necessity
guidelines/criteria for behavioral health services is
governed by the policies and procedures under
Optum, a fully National Committee for Quality
Assurance (NCQA) accredited managed behavioral
health organization, Mass General Brigham Health
Plans’ behavioral health delegate, and accepted by,
Mass General Brigham Health Plans’ Medical Policy
Committee (MPC). Development, review and
application of medical necessity guidelines/criteria for
genetic and molecular pathology testing is governed
by the policies and procedures under, eviCore
healthcare, an NCQA certified utilization management
organization, a utilization management delegate and
accepted by , Mass General Brigham Health Plans’
MPC .Development, review and application of medical
necessity guidelines/criteria for sleep studies are
governed by the policies and procedures under
CareCentrix a utilization management delegate.
Medical necessity guidelines and criteria are based
on sound clinical evidence of safety and efficacy and
developed and amended using various professional
and government agencies and local health care
delivery plans.
The Utilization Management Care Manager and/or
physician reviewer evaluates all relevant information
before making a determination of medical necessity.
Clinical guidelines and criteria are used to facilitate
fair and consistent medical necessity decisions. At a
minimum, the Utilization Management Care Manager
considers the following factors when applying criteria
to a given member: age, co- morbidities,
complications, progress of treatment, psychosocial
situation, home, and family environment, when
applicable. Medical necessity criteria are applied in
context with individual member’s unique
circumstances and the capacity of the local provider
delivery system. When criteria do not appropriately
address the individual member’s needs or unique
circumstances, the Utilization Management Care
Manager and/or physician reviewer may override the
criteria for an approval of services.
Providers can obtain a copy of internally developed
criteria used for a specific determination of medical
necessity by accessing
massgeneralbrighamhealthplan.org. Proprietary
criteria are made available to providers and members
on request and only to the extent it is relevant to the
particular treatment or service.
MassHealth’s Definition of Medical Necessity
Medically necessary services for Mass General
Brigham ACO members are those health care
services:
• Reasonably calculated to prevent, diagnose, prevent
the worsening of, alleviate, correct, or cure conditions
in the member that endanger life, cause suffering or
pain, cause physical deformity or malfunction,
threaten to cause or to aggravate a disability, or result
in illness or infirmity.
• For which there is no comparable medical service or
site of service available or suitable for the member
requesting the service that is more conservative or
less costly of a quality that meets professionally
recognized standards of health care, and must be
substantiated by records including evidence of such
medical necessity and quality.
Information Request
PROVIDER SERVICE
Phone 855-444-4647
Mon.-Fri. 8:00 a.m.-5:00 p.m.
Closed 12:00pm – 12:45pm.
ACO MEMBER SERVICE
Phone 800-462-5449 TTY 711
Email: HealthPlanCustomerService-
Mon.-Fri. 8:00 a.m.-6:00 p.m.
Thursday, 8:00 a.m.-8:00 p.m.
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For after-hour requests and utilization management
issues, these lines are available 24 hours a day, seven
days a week. All requests and messages will be
retrieved on the next business day. Language
assistance is available to all members.
Medical Necessity Denials
A medical necessity denial (adverse determination) is
a decision made to deny, terminate, modify, or
suspend a requested health care benefit based on
failure to meet medical necessity, appropriateness of
health care setting, or criteria for level of care or
effectiveness of care.
Only a Mass General Brigham Health Plan physician
reviewer or physician designee may make medical
necessity determinations for denial of service.
Appropriate Mass General Brigham Health Plan
network specialists and external review specialists are
used for complex specialty reviews and to review new
procedures or technology. Clinical peer review may be
requested for services that are denied prospectively
or concurrently on the basis of medical necessity.
Clinical peer review is an informal process offered to
providers. It is not an appeal nor is it a precondition
for filing a formal appeal. A physician reviewer
conducts the Clinical peer review within one business
day of the request.
Written notifications of medical necessity denials
contain the following information:
• The specific information upon which the denial
was made
• The member’s presenting symptoms or
condition, diagnosis and treatment interventions
and the specific reasons such medical evidence
fails to meet the relevant medical necessity
review criteria
• Specification of any alternative treatment option
that is available through Mass General Brigham
Health Plan Mass General Brigham Health Plan or
the community, if any
• A summary of the applicable medical necessity
review criteria and applicable clinical practice
guidelines
• How the provider may contact a physician
reviewer to discuss the denial
• A description of the formal appeals process, the
mechanism for instituting the appeals process,
and the procedures for obtaining an external
review of the decision
Administrative Denials
Administrative denials for authorization of
requested services or payment for services
rendered may be made when:
Member issued
• A service is explicitly excluded as a covered
benefit under the member’s benefit plan.
• The requested benefit has been exhausted.
Provider only issued
• A service was provided without obtaining the
required prior authorization.
• Required notification was not made in a timely
manner.
• Failure to submit clinical documentation
necessary to make a medical necessity
determination with the requested service.
Mass General Brigham Health Plan network providers
are contractually prohibited from holding any Mass
General Brigham ACO patient financially liable for any
service administratively denied by Mass General
Brigham Health Plan for failure of the provider to
adhere to established utilization processes.
Delegation of Utilization Management
Mass General Brigham Health Plan delegates some
utilization management activities to external entities
and provides oversight of those entities. UM
delegation arrangements are made in accordance
with the requirements of the National Committee on
Quality Assurance (NCQA), the Massachusetts Division
of Insurance, the Executive Office of Health, and
Human Services (EOHHS), and other regulatory
requirements.
• Optum for the utilization and care management
of behavioral health services on behalf of Mass
Mass General Brigham Health Plan—Provider Manual 6 –Clinical Programs and Utilization Management
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General Brigham Health Plan patients. Optum is a
fully NCQA accredited Managed Behavioral Health
Organization.
• Optum Rx has been delegated certain utilization
management functions for a select group of
pharmaceuticals. Mass General Brigham Health
Plan’s Pharmacy and Therapeutics Committee
approves all pharmaceuticals to be included in
Optum Rx’s prior authorization process. The
responsibility for making denials based on medical
necessity remains with Mass General Brigham
Health Plan.
• eviCore Healthcare has been delegated the
following elective outpatient services requiring
prior authorization through eviCore Healthcare:
Selected Molecular & Genetic Testing
• When these services are rendered as part of a
hospital emergency room, observation stay,
surgical care or inpatient stay, they are not
subject to prior authorization requirements.
• CareCentrix, Inc (CCX) has been delegated sleep
diagnostic and therapy management services.
• Medical Review Institute of America (MRIoA) has
been delegated to supplement the prior
authorization review process. MRIoA is an
external review organization that is staffed with
board-certified physicians with a wide variety of
specialties. In the rare instance when Mass General
Brigham Health Plan physician reviewers are
unavailable, MRIoA will provide support for the UM
reviews. In these instances, MRIoA representatives
may reach out to the requesting provider to obtain
additional clinical information or conduct a
physician-to- physician review.
Mass General Brigham Health Plan maintains close
communications with its delegated partners to ensure
seamless operations and positive member and
provider experiences.
Nurse Advice Line
Mass General Brigham ACO members have access to
a toll free 24/7 Nurse Advice Line. Patients can speak
directly with a registered nurse at any time of the
day, seven days a week. Members may also listen to
automated information on a wide range of health-
related topics, ranging from aging and women’s
health to nutrition and surgery. The Nurse Advice
Line does not take the place of a primary care visit. It
is intended to help our members decide if they
should make an appointment with their PCP or go to
the emergency room. The nurse also provides
helpful suggestions for how your patients might care
for themselves at home.
Your patients may access the Mass General Brigham
ACO Nurse Advice Line at 1-833-372-5644
Online Clinical Reports on the
Provider Portal
Clinical reports to help effectively manage patients
are available via the provider portal. This provision of
timely, actionable site and patient-level data allows
PCPs to download electronic versions of a variety of
reports and analyze the data based on the specific
needs of their practice.
Available reports include both quality and utilization
information. This includes both quality measures and
utilization for members with asthma and diabetes as
well as ER utilization.
Access to the data is entirely at the discretion of the
provider office. To protect the confidentiality of our
members and due to the sensitive contents of these
reports, providers are strongly encouraged to grant
role-based access only and review user permissions
regularly.
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Section 7: Billing guidelines
Billing, Reimbursement,
and Claims Submission 7-1
Submitting a Claim 7-1
Corrected Claim 7-2
Claim Adjustments/Requests for Review 7-2
Behavioral Health Services Claims 7-3
Billing for Professional Services,
Durable Medical Equipment, and Supplies 7-3
Billing for Inpatient
and Outpatient Facility Services 7-3
Coordination of Benefits (COB) Guidelines 7-4
Third Party Liability Claims 7-4
Workers Compensation (EC) Claims 7-4
Reconciling Mass General Brigham
Health Plan’ Explanation of Payment (EOP) 7-4
Provider Reimbursement 7-5
Serious Reportable Events/Occurrences 7-5
Billing for Missed Appointments 7-6
Audits 7-7
General Claims Audit 7-8
External Hospital Audits 7-8
Physician and Ancillary Audits 7-9
Payment Guidelines 7-9
Mass General Brigham Health Plan—Provider Manual 7 – Billing Guidelines
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Section 7: Billing guidelines
Chapter 2 Billing, Reimbursement,
and Claims Submission
Submitting a Claim
Mass General Brigham Health Plan manages the claims
processing for Mass General Brigham ACO. Mass
General Brigham Health Plan is committed to
processing clean claims within at least 45 days of
receipt. The claim receipt’s Julian date is embedded in
the Mass General Brigham Health Plans claim number
as shown on the Explanation of Payment (EOP).
A clean claim is defined as one that includes at least
the following information:
• Full member name
• Member’s date of birth
• Full Mass General Brigham Health Plan member
identification number
• Date of service
• Valid diagnosis code(s)
• Valid procedure code(s)
• Valid place of service code(s)
• Charge information and units
• National provider identifier (NPI) group number
• NPI rendering provider number, when applicable
• Vendor name and address
• Provider’s federal tax identification number
Claim Submission Guidelines
When using a billing agent or clearinghouse, providers
are responsible for meeting all Mass General Brigham
Health Plan claim submission requirements.
Mass General Brigham Health Plan requires the
submission of all paper and electronic claims within
90 days of the date of service unless otherwise
contractually agreed.
Mass General Brigham Health Plan will not accept
handwritten claims or handwritten corrected claims.
Mass General Brigham Health Plan will only accept
claims for services that you, your organization or your
staff perform. Pass-through billing is not permitted
and may not be billed to our members.
Mass General Brigham Health Plan’s claim submission
guidelines are as follows:
Claim Type
Submission
Format
Professional Charges
CMS-1500
Durable Medical Equipment
(DME)
CMS-1500
DME Supplies,
Home Infusion Services, etc.
CMS-1500
Institutional/Facility Charges
UB-04
EDI (Electronic) Claims
Claims submitted electronically are subject to the
claim edits established by Mass General Brigham
Health Plan. Mass General Brigham Health Plan’ payer
ID number is 04293. Companion Guides are available
to assist providers interested in electronic claim
submissions.
For questions regarding electronic claims submissions,
please contact Mass General Brigham Health Plan
Provider Service at
855-444-4647.
Paper Claims
Paper claims must be submitted on the proper forms
within the aforementioned time frames or per specific
contract arrangements. Claim forms other than those
noted above cannot be accepted. Mass General
Brigham Health Plan’s front-end edits apply to both
EDI and paper claim submissions.
NEW CLAIMS ONLY
Mail: Mass General Brigham Health Plan
P. O. Box 323
Glen Burnie, MD 21060
This address is for submission of brand-new paper
claims only. To avoid processing delays, please do not
send claims adjustment requests or any other
Mass General Brigham Health Plan—Provider Manual 7 – Billing Guidelines
7-2 2024-05-01
correspondence to this address. Address all other
correspondence as shown below.
CLAIM ADJUSTMENT REQUESTS
Mail: Mass General Brigham Health Plan Attn:
Correspondence Department
399 Revolution Drive, Suite 810
Somerville, MA 02145
CLAIMS APPEAL REQUESTS
Mail: Mass General Brigham Health Plan
Attn: Appeals Department
399 Revolution Drive, Suite 810
Somerville, MA 02145
Corrected Claims
Mass General Brigham Health Plan accepts both
electronic and paper corrected claims, in accordance
with guidelines of the National Uniform Claim
Committee (NUCC) and HIPAA EDI standards.
Corrected claims must be submitted with the most
recent version of the claim to be adjusted. For
example: a corrected claim to the original claim
(00000E00000) should include the original claim
number. A second corrected claim request should
include the latest version (00000E00000A1).
Electronic Submissions
To submit a corrected facility or professional claim
electronically:
• Enter the frequency code (third digit of the bill
type for institutional claims; separate code for
professional claims) in Loop 2300, CLM05-3 as
either “7” (corrected claim), or “8” (void or
cancel a prior claim).
• Enter the original claim number in Loop 2300,
REF segment with an F8 qualifier. For example,
for claim #12234E01234, enter
REF*F8*12234E01234.
Provider payment disputes that require additional
documentation must be submitted on paper, using
the Request for Review Form.
Late Charge Billing
Mass General Brigham Health Plan accepts corrected
claims to report services rendered in addition to the
services described on an original claim. Mass General
Brigham Health Plan will not accept separate claims
containing only late charges.
Mass General Brigham Health Plan will not accept Late
Charge claims from institutional (facility) providers,
including but not limited to: hospitals; ambulatory
surgery centers; skilled nursing facilities (SNF);
hospice; home infusion agencies; or home health
agencies.
Claim Adjustments/Requests for Review
Request for a review and possible adjustment of a
previously processed claims (not otherwise classified
as an appeal) should be submitted to the Claim
Adjustment Requests mailbox within 90 days of the
EOP date on which the original claim was processed.
All such requests should be submitted by completing a
Request for Review Form and including any supporting
documentation, with the exception of electronically
submitted corrected claims.
Filing Limit Adjustments
To be considered for review, requests for review and
adjustment for a claim received over the filing limit
must be submitted within 90 days of the EOP date on
which the claim originally denied. Disputes received
beyond 90 days will not be considered.
If the initial claim submission is after the timely filing
limit and the circumstances for the late submission are
beyond the provider’s control, the provider may
submit a request for review by sending a letter
documenting the reason(s) why the claim could not be
submitted within the contracted filing limit along with
any supporting documentation. Documented proof of
timely submission must be submitted with any
request for review and payment of a claim previously
denied due to the filing limit. A completed Request for
Review Form must also be sent with the request.
For paper claim submissions, the following are
considered acceptable proof of timely submission:
• A copy of the computerized printout of the Patient
Account Ledger indicating the claim was billed to
Mass General Brigham Health Plan, with the
submission date circled in black or blue ink.
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• Copy of Explanation of Benefits (EOB) from the
primary insurer that shows timely submission (90
days) from the date carrier processed the claim.
• Proof of follow-up with the member for lack of
insurance information, such as proof that the
member or another carrier had been billed, if the
member did not identify him/herself as a Mass
General Brigham Health Plan member at the time
of service.
• For EDI claim submissions, the following are
considered acceptable proof of timely submission:
• For claims submitted though a clearinghouse: A
copy of the transmission report and rejection
report showing the claim did not reject at the
clearinghouse, and the claim was accepted for
processing by Mass General Brigham Health Plan
within the time limit.
• For claims submitted directly to Mass General
Brigham Health Plan: The corresponding report
showing the claim did not reject at Mass General
Brigham Health Plan and was accepted for
processing by Mass General Brigham Health Plan
within the time limit.
• Copy of EOB from the primary insurer that shows
timely submission from the date that carrier
processed the claim.
A copy of the Patient Account Ledger is not
acceptable documentation for EDI claims except
when the patient did not identify him/herself as a
Mass General Brigham Health Plan patient at the
time of service.
The following are not considered to be valid proof of
timely submission:
• Copy of original claim form
• Copy of transmission report without matching
rejection/error reports (EDI)
• A Mass General Brigham Health Plan rejection
report or a report from the provider’s
clearinghouse without patient detail.
• A computerized printout of the Patient Account
ledger stating “billed carrier”
• A computerized printout of the Patient Account
ledger stating another carrier was billed in error,
where Mass General Brigham Health Plan is the
primary carrier via the New England Healthcare
Exchange Network
• Hand-written Patient Account Ledger
• Verbal requests
Behavioral Health Services Claims
Mass General Brigham Health Plan’s benefit is
administered through Optum. Claims, appeals, and
adjustment requests for behavioral health specific
services must be submitted to Optum directly.
Billing for Professional Services, Durable
Medical Equipment, and Supplies
Professional charges, as well as DME and supplies
must be billed on a CMS-1500 claim form and
include all pertinent and/or required information.
Missing, incomplete, or invalid information can
result in claim denials.
In addition, the group and the rendering clinician’s NPI
numbers are required on most professional claim
submissions. Claims submitted without a valid number
are subject to rejection by Mass General Brigham
Health Plan.
Billing for Inpatient and Outpatient Facility
Services
Institutional charges must be billed on a UB-04 claim
form and include all pertinent and/or required
information. Where appropriate, valid ICD-10, revenue
(REV), CPT-4 and/or HCPCS, and standard three-digit
type of bill codes are required on institutional claims.
Mass General Brigham Health Plan requires the
facility’s NPI on all institutional claim submissions.
Claims submitted without valid numbers are subject
to rejection by Mass General Brigham Health Plan.
Room Charges
Mass General Brigham Health Plan covers only the
semiprivate room rate unless a private room is
preauthorized. When not pre-authorized, the
semiprivate room rate will be applied to all private
room charges during claim adjudication.
Itemization
Itemization of inpatient charges is required upon
request with each day of service separately reported.
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Please refer to Mass General Brigham Health Plan’s
UB-04 Claim Form Completion Guidelines for more
information on required fields.
Coordination of Benefits (COB) Guidelines
COB is the process to determine how medical, dental,
and other health care services will be paid when a
person is covered under more than one insurer.
Providers are required to notify Mass General
Brigham Health Plan when other coverage is
identified. The COB team can be reached at 617-772-
5729 (prompt #1). Providers should use a TPL
Indicator Form for reporting other insurance
information discovered during patient encounters for
all Mass General Brigham Health Plan members.
These forms are available to providers by calling
Provider Service.
Providers are responsible for verifying eligibility at
the point of service, which includes possible
Medicare coverage. This is particularly important
given Medicare’s 12-month filing limit and the
significant reductions to allowed exceptions. Please
note that an EOP from another insurer no longer
qualifies as one of the exceptions.
The order of benefit determination is the term used
for establishing the primary versus secondary insurer
or carrier. The primary carrier must pay its portion of
the claim first before billing the secondary carrier for
review and potential payment of the balance up to its
benefit or policy limits. When Mass General Brigham
Health Plan is the secondary carrier, all claims must be
submitted with a copy of the primary carrier’s EOP,
remittance advice, or denial letter.
When a patient enrolls with Mass General Brigham
ACO Mass General Brigham Health Plan is always the
payer of last resort. All payments for covered Mass
General Brigham ACO services rendered are
considered as payment in full.
Services and charges must be billed on an appropriate
claim form and submitted to Mass General Brigham
Health Plan within 90 days of receipt of the
Explanation of Payment (EOP) or remittance advice
from the primary insurance carrier.
Third-Party Liability Claims
When a Mass General Brigham ACO Mass member is
involved in an automobile accident or a slip and fall
accident or has suffered an injury as a result of
another party’s negligence, providers should notify
Mass General Brigham Health Plan directly by calling
the Third-Party Liability Department at 617-772-5729
(prompt #2) and making the proper notation on
submitted claims. A Mass General Brigham Health
Plan representative can assist with the process of
determining which carrier should be billed for
services. Mass General Brigham Health Plan
Mass General Brigham Health Plan reserves the right
to subrogate and succeed to any right of recovery for
any services provided to a member injured in a third-
party accident.
Workers Compensation (WC) Claims
When a Mass General Brigham ACO member is injured
on the job, the employer’s workers compensation
carrier should be billed directly for the services. Only
upon denial from the workers compensation carrier
will Mass General Brigham Health Plan consider
additional claims.
Chapter 3 Reconciling Mass General
Brigham Health Plan’ Explanation of
Payment (EOP)
Each EOP claim line reflects the specific service
codes billed to Mass General Brigham Health Plan.
Denied claim lines will have corresponding
“Remarks” explaining the reason for the denial.
A claim line can be denied for many reasons, including
but not limited to:
• The payment submitted is included in the
allowance for another service/procedure.
• The service code submitted is not within the Mass
General Brigham Health Plan contract.
• The member was not effective for some or all
dates of service (i.e., Mass General Brigham
Health Plan was billed for five days but the
member was effective for only three of those
days).
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• The time limit for filing the claim has expired.
• A required authorization is required and not
on file.
Providers with questions or concerns on the
disposition of a denied claim should first validate
that all reasons for the claim denial have been
considered before re-submitting to Mass General
Brigham Health Plan.
Providers are strongly encouraged to reconcile the
EOP timely or at least within 90 days of receipt.
Requests for adjustments or corrections received
beyond the 90-day adjustment request filing limit
cannot be considered for reprocessing.
To assist in reconciling, Mass General Brigham Health
Plan offers instant access to PDF versions of current
and historical EOP copies on our secure provider
portal, Mass General Brigham Health Plan Provider
Portal. To enroll in the provider portal, simply follow
the easy registration instructions, or consult with your
site’s appointed user administrator.
Chapter 4 Provider Reimbursement
Reimbursement for services rendered must be treated
as payment in full. Providers may not seek or accept
payment from a Mass General Brigham Health Plan
patient for any covered service rendered. In addition,
providers may not have any claim against or seek
payment from MassHealth for any Mass General
Brigham Health Plan covered service rendered to a
Mass General Brigham Health Plan patient. Providers
should look solely to Mass General Brigham Health
Plan for payment with respect to Mass General
Brigham Health Plan covered services rendered.
Furthermore, a provider may not maintain any action
at law or in equity against any member or MassHealth
to collect any sums that are owed to the provider by
Mass General Brigham Health Plan for any reason, up
to and including Mass General Brigham Health Plan’
failure to pay, insolvency, or otherwise breach of the
terms and conditions of the Mass General Brigham
Health Plan Provider Agreement.
In the event that a non-medically necessary or non-
Mass General Brigham Health Plan covered service is
provided in place of a covered service, the provider
may not seek reimbursement from the member unless
documentation is provided indicating the provider
explained the liability of payment for the
nonmedically necessary or non-Mass General Brigham
Health Plan covered service to the member prior to
services being rendered. Documentation must
indicate that the member both understood and
agreed to accept liability for payment at the time of
service.
Serious Reportable Events/Occurrences
A serious reportable event (SRE) is an event that
occurs on the premises of a provider’s site that results
in an adverse patient outcome, is identifiable and
measurable, has been identified to be in a class of
events that are usually or reasonably preventable, and
is of a nature such that the risk of occurrence is
significantly influenced by the policies and procedures
of the provider.
Potential SREs or quality of care (QOC) occurrences
may be identified by members, providers, or Mass
General Brigham Health Plan staff and may come into
Mass General Brigham Health Plan through Customer
Service or any other department. The duty to report a
SRE is the responsibility of the individual facility or
provider. The facility or provider must document their
findings; and provide a copy of the report to both the
MA Department of Public Health (DPH) and to the
Mass General Brigham Health Plan Director of Quality
Management and Improvement within the required
time frame.
Issues of concern may also be found through claims
data or when medical record audits are performed by
Mass General Brigham Health Plan. Claims data are
reviewed on a quarterly basis to identify possible
SREs. Any problems identified include both acts of
commission and omission, deficiencies in the clinical
quality of care, inappropriate behavior during the
utilization management process, and any instances of
provider impairment documented to be a result of
substance abuse or behavioral health issues. All
contracted providers must participate in and comply
with programs implemented by the Commonwealth of
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Massachusetts through its agencies, such as, but not
limited to the Executive Office of Health and Human
Services (EOHHS), to identify, report, analyze and
prevent SREs, and to notify Mass General Brigham
Health Plan of any SRE.
Mass General Brigham Health Plan reviews and
promptly responds within 30 days to actual or
potential QOC occurrences. The provider will have
within seven days to report SREs. Mass General
Brigham Health Plan uses the National Quality
Forum’s (NQF) definition of SREs (referred to as
“never events”)
and the NQF’s current listing of “never events.”
Mass General Brigham Health Plan does not reimburse
services associated with SREs, “never events,” and/or
provider preventable conditions.
To administer this policy, Mass General Brigham
Health Plan recognizes but is not limited to the SREs
identified by the National Quality Forum,
HealthyMass, and the CMS Medicare Hospital
Acquired Conditions (Present on Admission Indicator)
reporting.
This policy applies to all hospitals and sites covered by
their hospital license, ambulatory surgery centers, and
providers performing the billable procedure(s) during
which an “event” occurred.
Mass General Brigham Health Plan will reimburse
eligible providers who accept transferred patients
previously injured by an SRE at another institution
(facility) or under the care of another provider.
On this example of an EOP section above, all claim
lines were denied, with corresponding explanations
below.
Billing for Missed Appointments
Mass General Brigham Health Plan considers a missed
appointment as factored into the overhead cost of
providing services and not a distinct reimbursable
service. In recognition of this, provider fee schedules
are designed to cover this cost, keeping the member
from incurring additional costs.
Mass General Brigham Health Plan expects that the
practice and its providers will cooperate and
participate with Mass General Brigham Health Plan in
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programs focused on improving member appointment
attendance.
Providers must not:
• Bill members for missed appointments.
• Refuse to provide services to members due to
missed appointments.
• Refuse to provide services to members because
the member has an outstanding balance owed to
the practice from a time prior to the patient
becoming a Mass General Brigham Health Plan
member.
Audits
Mass General Brigham Health Plan’ audit process
ensures accuracy of charges and consistency with
plan policies, provider agreements, and applicable
nationally recognized medical claims
reimbursement and administration policies. Mass
General Brigham Health Plan auditing specialists,
possessing thorough knowledge of medical
procedures, terminology, and procedural coding,
will perform the audits, review findings, and
respond to provider questions or concerns.
Audits may be conducted on claims paid during the
current year or two prior Mass General Brigham
Health Plan fiscal (calendar) years and up to six years
when investigating possible cases of fraud or abuse.
Mass General Brigham Health Plan policies, including
but not limited to medical policies, claims
administration policies, and provider payment
guidelines, will apply to all reimbursement and claims
matters. In any matter where Mass General Brigham
Health Plan does not maintain a specific policy or
guideline, Mass General Brigham Health Plan adopts
and follows the national standards and policies
relating to procedural coding, medical claims
administration, and reimbursement, which are
recognized by government payers such as the Centers
for Medicare and Medicaid Services (CMS), national
health insurance carrier organizations, local coverage
determinations (LCDs), and the American Medical
Association (AMA).
Pursuant to the Mass General Brigham Health Plan
Provider Agreement, Mass General Brigham Health
Plan has the right to inspect, review, and make copies
of medical records. All requests for medical record
review are made in writing. The inspection of medical
records is conducted in compliance with the provider’s
standard policies governing such processes and that
are applied uniformly to all payers.
Provider notification includes the audit parameters
and corresponding medical records. The number of
selected medical records is determined based on
generally accepted statistical sampling methodology,
rules, and techniques recognized in the field of
statistical probability. Should additional areas of
questions be identified, Mass General Brigham Health
Plan reserves the right, at its election, to expand the
scope of any audit, and perform extrapolation of audit
results to the defined audit population. If
extrapolation methodology is selected, the process
shall be performed in accordance with generally
accepted sampling principles as outlined above. Mass
General Brigham Health Plan strictly adheres to state
and federal requirements regarding confidentiality of
patient medical records. A separate consent form will
be provided when required by law.
When an initial review of a provider’s medical records
is required, Mass General Brigham Health Plan’
provider audit process includes written 30-days’ prior
notification. For on-site audits, the provider must
arrange a suitable work area, and make available to
the auditor the medical records, including but not
limited to pharmacy profile and corresponding fee
book when applicable. The fee book should be an
electronic file (Excel or similar program) unless
another format has been agreed upon.
When additional records or documentation are
necessary to complete the audit, the auditor will
submit a written request for information to the
provider’s representative identifying the necessary
documents to complete the audit, specifying a
reasonable time period within which the provider will
supply the requested documents.
Unless otherwise contractually agreed upon, Mass
General Brigham Health Plan does not reimburse
for audit-related administrative fees incurred by a
provider.
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General Claims Audits
General post payment claims audits are conducted to
identify the accuracy of charges and the consistency of
claims reimbursement with Mass General Brigham
Health Plan’s policies, Provider Agreements, Payment
Guidelines, and applicable nationally recognized
medical claims reimbursement and administration
policies, including but not limited to: CPT, MassHealth,
and CMS guidelines. Audits include, but are not
limited to:
• Billing for services at a higher level than provided
• Billing for services not documented and not
provided
• Incorrect coding, including unbundling component
service codes, modifier usage, units of service,
and duplicate payments
• Historical claim audits to include the global
surgical period for codes submitted on the current
claim
• Medical necessity based on Mass General Brigham
Health Plan and/or CMS guidelines as applicable
to the member benefit plan
For claim overpayments greater than $500, the
provider is notified in writing from Mass General
Brigham Health Plan 30 or more days prior to the
retraction of any monies identifying claim
discrepancies totaling over $500 per vendor that have
been identified by Mass General Brigham Health Plan’
post payment audit resulting in claim adjustments. All
adjustments are processed against future payments.
Unless otherwise instructed, providers should not
issue a refund to Mass General Brigham Health Plan
for overpayments identified by Mass General Brigham
Health Plan. (However, this does not alter the
Provider’s obligation under federal or state law to
report and return any overpayments.)
If the provider disagrees with the adjustments, a letter
of appeal or a completed Mass General Brigham
Health Plan Provider Audit Appeal Form may be
submitted to Mass General Brigham Health Plan’
Appeals department within 90 days of receipt (or 30
days if requesting an extension), along with
comprehensive documentation to support the dispute
of relevant charges. Mass General Brigham Health
Plan will review the appeal and, when appropriate,
consult with Mass General Brigham Health Plan
clinicians or subject matter experts in the areas under
consideration. To the extent that the provider fails to
submit evidence of why the adjustment is being
disputed, the provider will be notified of Mass General
Brigham Health Plan’ inability to thoroughly review
the appeal request. The provider can resubmit
(provided this occurs within the 90 days EOP window)
and the appeal’s receipt date will be consistent with
the date Mass General Brigham Health Plan received
the additional documentation.
Mass General Brigham Health Plan will review the
appeal and, when appropriate, consult with clinicians
or subject matter experts in the areas under
consideration. The appeal determination will be final
and if the determination is favorable to the provider,
the claims in question will be adjusted accordingly
within 10 calendar days of the final determination
notification.
External Hospital Audits
Audits are conducted at a mutually convenient time
and cancellations by either party require written 15
days advance notice. In the event that an audit is
cancelled, the audit must be rescheduled within 45
days of the originally scheduled date. Mass General
Brigham Health Plan’ audits involving inpatient, and
outpatient claims also include an exit interview to
review and discuss the findings.
Documented unbilled services are charges for
documented services that were detailed and billed for
on the original audited claim but not billed to the full
extent of the actual services provided. These charges
will be considered for payment only when an
accounting of the services is presented at the time of
the on-site audit review for verification and
acceptance during the on-site audit review. In
addition, the charges must be submitted on a Mass
General Brigham Health Plan accepted claim form. The
accepted charges will be adjusted (netted out) against
the unsupported charges at the conclusion of the
audit.
If there is a question of medical necessity or level of
care, the hospital designee will coordinate
dissemination and review of the findings with hospital
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staff and present a rebuttal position prior to the exit
interview or within the 30-day appeal period.
At the conclusion of the audit, if the hospital designee
agrees with the findings, the auditor will provide a
dated copy of the signed and final Discrepancy Report.
Adjustments will be made 30 calendar days after the
date indicated on the Discrepancy Report and will
reflect accordingly in subsequent EOPs. Alternative
arrangements for payment to Mass General Brigham
Health Plan must be made in writing and signed by all
parties.
Physician and Ancillary Audits
Physician and ancillary provider audits may consist of
both off-site and on-site audits, with the audit of
designated medical records conducted at either Mass
General Brigham Health Plan or the vendor’s office,
when applicable. The determination of an off-site
and/or on-site audit will be made by Mass General
Brigham Health Plan.
Adjustments will be made 30 calendar days after the
date indicated on the Discrepancy Report and will
reflect accordingly in subsequent EOPs. Alternative
arrangements for payment to Mass General Brigham
Health Plan must be made in writing and signed by all
parties.
Hold Harmless Provision
Providers contractually agree that in no event,
including, but not limited to, non-payment by Mass
General Brigham Health Plan, Mass General Brigham
Health Plans’ insolvency, or breach of the Provider
Agreement, should a provider or any of its medical
personnel bill, charge, collect a deposit from, or have
any recourse against any Mass General Brigham
Health Plan member or person, other than Mass
General Brigham Health Plan, acting on their behalf
for services provided. The provider must not solicit or
require from any member or in any other way
payment of any additional fee as a condition for
receiving care. Providers must look solely to Mass
General Brigham Health Plan for payment with respect
to covered services rendered to all Mass General
Brigham Health Plan members.
This provision does not prohibit collection of
supplemental charges or copayments on Mass
General Brigham Health Plan’ behalf made in
accordance with the terms of the applicable
Subscriber Group Agreement between Mass General
Brigham Health Plan and the member.
Payment Guidelines
Mass General Brigham Health Plan’ payment
guidelines are designed to help with claim submissions
by promoting accurate coding and by clarifying
coverage. Mass General Brigham Health Plan’
payment guidelines are found at Provider payment
guidelines | Mass General Brigham Health Plan.
Mass General Brigham Health Plan—Provider Manual 8 – Pharmacy
8-0 2024-05-01
Section 8: Pharmacy
Optum Rx 8-1
Formulary Drug Lookup Tool 8-1
Pharmacy Copayment 8-1
Copayment Exemptions 8-1
E-prescribing 8-1
Pharmacy Coverage 8-1
Over-the-Counter Benefit 8-1
Generic Interchange Policy 8-2
Exception Requests 8-2
Quantity Limitations 8-2
Prior Authorization Drug Policy 8-2
Step-Therapy Programs 8-2
Specialty Medications Programs 8-2
Maintenance 90 Program 8-3
Access90 Program 8-3
Medicare Part D 8-3
More Information 8-4
Optum Rx Contact Information: 8-4
Mass General Brigham Health Plan—Provider Manual 8 – Pharmacy
8-1 2024-05-01
Section 8: Pharmacy
Optum Rx
Mass General Brigham Health Plan has partnered
with Optum Rx for pharmacy benefit management
services. Optum Rx provides members with access to
a comprehensive retail pharmacy network, as well as
administers a variety of services including pharmacy
claims processing, and specialty and formulary
management.
Formulary Drug Lookup Tool
The Searchable Formulary Drug Lookup Tool for
clinicians is designed to provide information about
Mass General Brigham Health Plan drug coverage. It
provides a searchable formulary by information such
as drug name, drug class, prior authorization, and
other limitations.
Mass General Brigham Health Plan encourages
providers to use the Formulary Drug Lookup Tool to
become familiar with the drug selection. Our
formulary is unified with the MassHealth Drug List
and is regularly reviewed and evaluated by the Mass
General Brigham Health Plan Pharmacy and
Therapeutics Committee. This committee is
comprised of representatives from various practices
and specialties.
Pharmacy Copayment
If a Mass General Brigham Health Plan patient is
unable to pay a copayment at the time of service, the
pharmacy must fill the prescription. However, the
pharmacy can bill the patient later for the copayment.
Copayment Exemptions
A Mass General Brigham ACO patient is exempt from
prescription co-pays if they:
• Are under 21 years old
• Are pregnant or pregnancy ended within 60 days of
the service
• Are receiving inpatient care at an acute hospital,
nursing facility, chronic disease or rehabilitation
hospital, or intermediate-care facility for the
developmentally delayed, or is admitted to a
hospital from such a facility
• Are receiving hospice care
• Are enrolled in MassHealth because they were in
the care and custody of the Department of Children
and Families (DCF) when they turned 18, and their
MassHealth coverage was continued
• Are Native American or Alaska Native from a
federally recognized tribe
• Have reached the pharmacy copayment cap for the
calendar year
• Have income at or below 50% federal poverty level
• Are categorically eligible for MassHealth because
they are receiving other public assistance
E-prescribing
E-prescribing is the transmission, using electronic
media, of a prescription or prescription-related
information, between a prescriber, dispenser,
pharmacy benefit manager, or health plan, either
directly or through an intermediary, including an e-
prescribing network such as Surescripts.
Mass General Brigham ACO understands and
embraces the value that e-prescribing brings to the
effective care of its members and continues its
commitment, along with its contracted pharmacy
benefits management partner, Optum Rx, in bringing
these capabilities to the provider community.
Specifically, Mass General Brigham ACO provides
patient eligibility/coverage status, medication history,
and formulary information to physicians who use
e-prescribing tools.
Pharmacy Coverage
Over-the-Counter Benefit
Mass General Brigham Health Plan covers many over-
the-counter products, including smoking deterrents.
To ensure safe and appropriate use, covered over-
the-counter items do require a prescription and must
be obtained from a participating pharmacy. Mass
General Brigham Health Plan’s pharmacy network
includes most Massachusetts pharmacies. (Refer to
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8-2 2024-05-01
Optum Rx’s Pharmacy Directory for a complete listing
of participating pharmacies). Visit Providers | Mass
General Brigham Health Plan for listing of some of the
covered over-the-counter medications available to
Mass General Brigham Health Plan patients.
Generic Interchange Policy
Mass General Brigham Health Plan has a mandatory
generic substitution policy. The generic equivalent
must be dispensed when available. Multisource brand
name drugs are not covered when a clinically
equivalent lower cost generic is available. Brand name
medications may be covered only when a generic is
not available.
Exception Requests
There may be cases where a medication, a quantity of
medication or a brand name medication is not
normally covered by Mass General Brigham Health
Plan, but the prescribing physician feels that it is
medically necessary for the patient. In these
instances, the physician can submit a fax form to
OptumRx, available on Providers | Mass General
Brigham Health Plan.
The medication prior authorization and step therapy
criteria can be found on Providers | Mass General
Brigham Health Plan.
Exception requests are reviewed by Optum Rx.
Because we are committed to providing our patients
with prompt access to care, decisions regarding
override requests are generally communicated within
24 hours to two business days from the time
complete medical documentation is received.
Quantity Limitations
Quantity limitations have been implemented on
certain medications to ensure the safe and
appropriate use of the medications. See the
Formulary Drug Lookup Tool to determine if a
medication has a quantity limitation.
Prior Authorization Drug Policy
To ensure appropriate utilization, Mass General
Brigham Health Plan delegates to OptumRx prior
authorization of some drugs. Prescribers can request
clinical reviews by calling the Prior Authorization (PA)
department at Optum Rx. Optum Rx staff will ask
several questions to determine if the patient meets
the established clinical criteria for the drug. After the
clinical review, if the medication is approved for the
patient, the Prior Authorization department at Optum
Rx will process the authorization and the pharmacy
will be systematically notified of the decision and can
then dispense the prescription. Please refer to the
Formulary Drug Lookup Tool for medications requiring
prior authorization. The clinical criteria for prior
authorizations are reviewed annually by our
Pharmacy and Therapeutics Committee and are
available in the pharmacy section of our website.
Step-Therapy Programs
Step therapy programs require use of specific, lower
cost, therapeutically equivalent medications within a
therapeutic class before higher cost alternatives are
approved. Prescriptions for “first-line” medication(s)
are covered; prescriptions for “second-line”
medications process automatically if the member has
previously received a first-line medication(s) in the
past 6–12 months of Mass General Brigham ACO
enrollment. The look-back period depends upon the
particular program. Physicians may submit an
override request to prescribe a second-line
medication prior to using a first-line medication or if
the member has previously failed a first-line
medication outside of the drug look-back period. The
request can be submitted by calling the Prior
Authorization (PA) department at Optum Rx, or by
faxing a request form. Step therapy programs are
reviewed by Mass General Brigham Health Plan’s
Pharmacy and Therapeutics Committee.
Specialty Medications Programs
Certain injectables or specialty medications
(Such as oral oncology) are covered only
when obtained from any Mass General Brigham
Health Plan’s contracted specialty pharmacy including
Optum Rx Specialty Pharmacy.
The Specialty Medications Program offers a less costly
method for purchasing expensive injectable drugs.
Providers may still choose to administer the
medications providing oversight to patients’ health
status. Under the program, medication and supplies
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will be shipped out and labeled specifically for each
patient and delivered to the provider’s office within
24 to 48 hours after ordering. Providers will then bill
Mass General Brigham Health Plan only for the
administration of the injectable drug.
In addition, for those injectable medications that are
self-administered or for patients with transportation
restrictions, the specialty pharmacy can ship
injectable medications and necessary administration
supplies, if applicable, directly to the patient’s homes.
Please visit Providers | Mass General Brigham Health
Plan for copies of the specialty pharmacy prior
authorization fax forms, the list of specialty drugs, and
medications supplied.
Mandatory 90 Program
The Mandatory 90 program requires a 90-day supply
to ensure the member always has the most important
medications on hand.
If the member is starting a new medicine, they will be
allowed to get a 30-day prescription first to make sure
the medicine is right for them. If they are staying on
the medicine, then they will be required to get a 90-
day supply.
Members will be automatically enrolled in this
program to get 90-day refills of ongoing
prescriptions after a 30-day. If you feel that your
patient should not be part of this program for one or
more of their medications, you should call Mass
General Brigham Health Plan Customer service to
request that your patient not be in the program.
Allowable 90 Program
Allowable 90 provides Mass General Brigham Health
Plan members with a 90-day supply of certain
maintenance medications when purchased through
participating pharmacies. This program allows Mass
General Brigham ACO patients to obtain a 90-day
supply of certain medicines at a reduced cost.
Medicare Part D
Certain Mass General Brigham ACO patients with
Medicare coverage and enrolled in MassHealth have
their prescriptions drug benefit covered by Medicare.
Mass General Brigham ACO patients received ID cards
for their Medicare prescription drug coverage.
Most prescription drugs are covered under their
Medicare benefit. Mass General Brigham Health Plan
does provide coverage for some drugs that are
excluded by the federal Medicare mandate. Examples
include certain over-the-counter drugs and vitamins.
For more information, please call Mass General
Brigham Health Plan Customer Service.
To find out more about Medicare’s prescription drug
coverage:
• Contact Medicare at 800-633-4227.
• Visit the Medicare website at www.medicare.gov.
• Go to www.cms.gov.
More Information
Updates to the formulary are communicated through
the provider
newsletters and the provider portal.
Optum Rx Contact Information:
Non-Specialty Fusion Requests
Phone: 800-711-4555
Fax: 844-403-1029
Specialty Fusion
Phone: 877-519-1908
Fax: 855-540-3693
Mass General Brigham HealthPlan MassHealth
Phone: 877-433-7643
Fax: 866-255-7569
Mass General Brigham Health Plan—Provider Manual 9 – Appeals and Grievances
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Section 9: Appeals and Grievances
Provider Grievances
and Administrative Appeals 9-1
Requesting an Administrative Appeal 9-1
Administrative Appeals Process 9-1
Appealing a Behavioral Health Service Denial 9-2
Post-Payment Claim Adjustments 9-2
Member Grievances and Inquiries 9-2
Inquiries 9-2
Grievances 9-3
Behavioral Health Inquiries and Grievances 9-4
Member Clinical Appeals 9-5
Expedited Clinical Appeals 9-5
Access to Appeal File by Member or Member
Representative 9-8
Consumer Protection from Collections and
Credit Reporting During Appeals 9-8
Behavioral Health Appeals 9-8
Mass General Brigham Health Plan—Provider Manual 9 – Appeals and Grievances
9-2 2024-05-01
Section 9:
Appeals and Grievances
Provider Grievances and
Administrative Appeals
Mass General Brigham Health Plan has a
comprehensive process for resolving appeals and
grievances.
An appeal is a request that Mass General Brigham
Health Plan or Optum review an adverse action or
denied claim, having provided documentation
supporting the request for reconsideration. Appeal
requests must be submitted in writing.
A grievance is any expression of dissatisfaction about
any action or inaction by Mass General Brigham
Health Plan other than an Adverse Action. Possible
subjects for grievances include, but are not limited to,
quality of care or services provided, aspects of
interpersonal relationships such as rudeness of a
provider or employee of Mass General Brigham
Health Plan, or failure to respect the member’s rights.
Grievances should be reported to Mass General
Brigham Health Plan’ Provider Service.
Requesting an Administrative Appeal
As described in the Billing Guidelines section or as
contractually agreed, providers can request a review
and possible adjustment of a previously processed
claim within 90 days of the Explanation of Payment
(EOP) date on which the original claim was processed.
If the provider is not satisfied with the decision, an
appeal can be submitted to Mass General Brigham
Health Plan’ Provider Appeals Department.
Appeal requests must be submitted in writing within
one of the following timeframes:
• 90 days from receipt of the EOP
• 90 days from receipt of EOP from other insurance
• 90 days from the date of the claim’s adjustment
letter
The appeal must include additional relevant
information and documentation to support the
request. Requests received beyond the 90-day appeal
request filing limit will not be considered.
When submitting a provider appeal, please use the
Request for Claim Review Form.
Appeals may be sent to:
Mail: Mass General Brigham Health Plan
Appeals & Grievances Dept.
399 Revolution Drive, Suite 810
Somerville, MA 02145
Fax: 617-526-1902
Administrative Appeals Process
Mass General Brigham Health Plan’ administrative
appeals option applies only for services already
rendered.
Administrative denial letters issued by Mass General
Brigham Health Plan’ Clinical Department informing
the provider that Mass General Brigham Health Plan
received insufficient documentation to make a
medical necessity decision require the submission of a
new approval request through the Mass General
Brigham Health Plan Provider Portal. Providers should
not appeal these denials. Instead, submit the
additional information requested through the
Provider Portal.
For denials on services already rendered, the Mass
General Brigham Health Plan administrative appeals
process includes two appeal levels:
• A Level I appeal is the initial request to Mass
General Brigham Health Plan for reconsideration
of a denied claim. Level I appeal submissions are
reviewed and completed within 30 calendar days
from the date Mass General Brigham Health Plan
receives the request with all supporting
documentation. If additional information is
needed to finalize the appeal request, the
provider will be notified in writing. The requested
documentation must be submitted within 60 days
from the date of Mass General Brigham Health
Plan’ Level I appeal letter.
• If approved, Mass General Brigham Health Plan
will adjust the claim. The provider will be notified
of the outcome via the Mass General Brigham
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Health Plan Explanation of Payment which should
reflect the reprocessed claim(s) within two weeks
once reprocessed.
• If denied, the provider will be notified in writing of
the reason and when applicable, provided with
instructions for filing a Level II appeal. A Level II
appeal provides the option to request a
reconsideration of the Level I appeal when the
provider has new and/or additional information
that supports the request for a second review.
The request for a Level II appeal needs to be
received by Mass General Brigham Health Plan
within 60 days of the Level I appeal denial letter.
Level II appeal decisions are considered final.
Appealing a Behavioral Health
Service Denial
Provider appeals and grievances for behavioral health
services are handled by Optum, Mass General
Brigham Health Plan’s Behavioral Health Partner. All
behavioral health appeals should be submitted
directly to Optum.
For more information, please refer to the Behavioral
Health Provider Manual or contact Optum at 844-
451-3519.
Post-Payment Claim Adjustments
Mass General Brigham Health Plan regularly reviews
claims post payment and adjust as needed.
Depending on the total dollars adjusted, Mass
General Brigham Health Plan proactively notifies the
provider of the scheduled adjustments. Providers who
disagree with these adjustments can submit a letter
of appeal or a completed Mass General Brigham
Health Plan Provider Audit Appeal Form to Mass
General Brigham Health Plan’ Appeals department
within 90 days of the Explanation of Payment (EOP)
along with comprehensive documentation to support
the dispute of relevant charges.
Appeals are reviewed within 30 calendar days from
Mass General Brigham Health Plan’ receipt of all
required documentation. When appropriate, Mass
General Brigham Health Plan will consult with
clinicians or subject matter experts in the areas under
consideration before finalizing the appeal request.
To the extent that the provider fails to submit
evidence of why the adjustment is being disputed, the
provider will be notified of Mass General Brigham
Health Plan’ inability to thoroughly review the
request. The provider can resubmit the appeal within
the 90 days of the EOP. The appeal’s receipt date will
be consistent with the date Mass General Brigham
Health Plan received the additional documentation.
The appeal determination will be final. If the appeal
request is upheld, Mass General Brigham Health Plan
will adjust the claims in question within 10 calendar
days of the final determination notification. Providers
are notified of the claim’s reprocessing via the EOP.
Member Grievances and Inquiries
Mass General Brigham Health Plan is committed to
ensuring member satisfaction and to the timely
resolution of reports of dissatisfaction by a member
(or the member’s representative on file) about any
action or inaction by Mass General Brigham Health
Plan or a health care provider. Mass General Brigham
Health Plan provides processes that allow for the
adequate and timely resolution of member
complaints/grievances.
Inquiries
Mass General Brigham Health Plan is also committed
to timely responding to all member inquiries.
An inquiry is any oral or written question made to
Mass General Brigham Health Plan’ Customer Service
regarding an aspect of Mass General Brigham Health
Plan’ operations that does not express dissatisfaction
about Mass General Brigham Health Plan.
Upon receipt of an inquiry, Mass General Brigham
Health Plan Customer Service Representative will
document the matter and, to the extent possible,
attempt to resolve it at the time of the inquiry.
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Grievances
Mass General Brigham Health Plan investigates all
reported incidents of dissatisfaction on the part of
Mass General Brigham Health Plan and/or a provider.
Possible subjects of grievances include, but are not
limited to:
• Quality of Care— Concerns with the quality of the
care and/or treatment provided by medical staff.
• Access— Reports of barriers to needed care in
accordance with wait-time access standards or in a
manner that met the member’s perceived needs.
Access is defined as the extent to which a member
can obtain services (telephone access and
scheduling an appointment) at the time they are
needed. It can also include wait time to be seen
upon arrival, and geographic distance to a network
provider.
• Service/Administration— Reports of poor member
experiences, including rudeness by Mass General
Brigham Health Plan and/or provider staff.
• Billing and Financial— A dispute of financial
responsibility for rendered services and/or rendered
as billed.
• Provider’s Facility— Reports that a provider’s facility
is deemed inadequate, including but not limited to
cleanliness of waiting room, restrooms, and overall
physical access to the premises.
• Privacy Violation— Member reports that a provider
and/or Mass General Brigham Health Plan violated
or compromised protected health information (PHI).
• Member Rights— Reports of violation of a member’s
rights by a provider and/or Mass General Brigham
Health Plan, including but not limited to Mental
Health Parity Laws violations.
When a member designates an authorized
representative to act on their behalf, such
representative is granted all the rights of a member
with respect to the grievance process, unless limited
in writing by the member, law, or judicial order.
The member must complete and return a signed and
dated Designation of Appeal or Grievance
Representative Form prior to the deadline for
resolving the grievance. If the signed form is not
returned, communication will only take place with the
member.
Mass General Brigham Health Plan ensures that any
parties involved in the resolution of grievances and
any subsequent corrective actions have the necessary
skills, training, and subject matter expertise to make
and implement sound decisions and that they have
not been involved in any previous level of review or
decision-making. Members or their representatives
are provided with a reasonable opportunity to
present evidence and allegations of fact or law, in
person as well as in writing.
A member may file a complaint or grievance by
telephone, fax, letter, or in person. Mass General
Brigham Health Plan Customer Service Professionals
provide assistance to members, including interpreter
services, TTY, and other options when explaining the
grievance or appeal process and assisting with the
completion of any forms.
Upon notification of a grievance, a Customer Service
Professional logs the details of the grievance and
refers the matter to the Appeals and Grievances
Department. An acknowledgement letter follows
within one business day requesting the member’s
review that Mass General Brigham Health Plan
Customer Service accurately captured the details and
to sign and return a copy to Mass General Brigham
Health Plan prior to the deadline for resolving the
grievance. However, the investigation of a member’s
grievance is not postponed pending return of this
signed letter. The member’s signature merely
acknowledges that Mass General Brigham Health Plan
has documented the details of the grievance
correctly.
A health care professional with the appropriate clinical
expertise in treating the medical condition, performing
the procedure, or providing treatment that is the
subject of a grievance will make an initial assessment
as to the clinical urgency of the situation and establish
a resolution time frame accordingly if the grievance
involves:
• The denial of a request that an internal appeal be
expedited
• Any clinical issue
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• The Mass General Brigham Health Plan
Appeals Committee will resolve a grievance
when the subject of the grievance involves:
• The denial of payment for services received
because of failure to follow prior authorization
procedures
• The denial of a request for an internal appeal
because the request was not made in a timely
fashion
• The denial of coverage for non-covered services
• The denial of coverage for services where benefit
limitations apply
When the subject matter involves the act or omission
on the part of a Mass General Brigham Health Plan
employee, resolution is made by the employee’s
department, when appropriate.
For grievances involving non-clinically related actions
or omissions of a provider, assistance from the
provider is requesting in investigating the grievance.
Network providers’ adherence to the grievance
process is monitored regularly to identify training and
other interventions.
For grievances specific to a provider, the nature of the
grievance will determine whether the matter is
addressed directly with the clinician or with the site’s
administrator. In either case, the provider is contacted
to discuss the matter and asked for a written response
addressing all identified concerns, corrective actions
taken and supporting documentation when applicable.
To allow timely completion of the review of all
relevant information within the specified time frame,
a response from the provider is expected within five
business days unless otherwise agreed upon.
Upon receipt and review of the provider’s response, a
written response is sent to the member containing
the substance of the complaint, the findings and
actions taken, while ensuring the appropriate
confidentiality rights of all parties. At a minimum, the
resolution will acknowledge receipt of the grievance
and that it has been investigated.
Grievances are researched and resolved as
expeditiously as warranted, but no later than 30
calendar days from the verbal or written notice of the
grievance. If the grievance resolution results in an
adverse action, the response letter will advise the
member of his or her right to appeal the decision.
Behavioral Health Inquiries and Grievances
Management for all behavioral health–related
inquiries and grievances is delegated to Mass
General Brigham Health Plan’s Behavioral Health
Partner, Optum.
For more information, please see the Behavioral
Health Provider Manual or contact Optum.
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Expedited Clinical Appeals
Standard Clinical Appeals
Level I Expedited Appeal (Level II = n/a)
A member, member representative, or provider may request an expedited internal appeal when the member’s life, health, or ability
to attain, maintain, or regain maximum function would be seriously jeopardized by waiting 30 calendar days for a standard appeal
resolution. Punitive action will not be taken against a provider who requests an expedited appeal on behalf of a member.
An expedited appeal must be filed within 30 calendar days of Mass General Brigham Health Plan’ decision to deny, terminate, modify,
or suspend a requested health care service.
Mass General Brigham Health Plan will continue to authorize disputed services during the formal appeal process if those services had
initially been authorized by Mass General Brigham Health Plan, unless the member indicates that they do not want to continue
receiving services, as long as the appeal request is submitted within 10 days of the adverse action.
Provider expedited appeal requests will be granted unless Mass General Brigham Health Plan determines that the provider’s request
is unrelated to the member’s health condition. To file an appeal on behalf of a member, the provider must submit to Mass General
Brigham Health Plan a written authorization from the member, designating the provider as their appeal representative. The Mass
General Brigham Health Plan Designation of Appeal Representative Form should be used for this purpose.
While Mass General Brigham Health Plan will not postpone the appeal pending receipt of the form, it must be provided within a
reasonable time period. If an expedited appeal request is not granted, the provider will receive timely notification of the decision
verbally, as well as written notification of the dismissal of the expedited appeal request within two calendar days.
The expedited appeal request will be processed in accordance with standard appeal time frames, with the member (or authorized
representative) notified accordingly.
If the request is denied, the member will be notified of their right to file a grievance. If approved, a decision will be communicated
within 72 hours of receipt. Providers are notified verbally and in writing on approved and denied requests.
The time frame for making expedited internal appeal resolutions may be extended for up to 14 calendar days if Mass General Brigham
Health Plan receives a request for an extension. For extension requests not initiated by the member, Mass General Brigham Health
Plan will notify the member in writing of their right to file a grievance
Expedited External Review
The expedited internal appeal process is limited to one appeal level. Otherwise, the decision may be appealed via the Office of
Medicaid Board of Hearings (BOH). The appeal must be submitted within 20 days of an expedited appeal decision. An appeal
submitted to the BOH within 21 to 30 days will be treated as a standard appeal.
To continue receiving ongoing services during a BOH expedited appeal, the Appeal must be requested within 10 calendar days of Mass
General Brigham Health Plan’ initial appeal decision to uphold the decision to deny, terminate, modify, or suspend a requested health
care service.
If the BOH determines that the member submitted the request for a BOH appeal in a timely manner, and the appeal involves the
reduction, suspension, or terminations of a previously authorized service, Mass General Brigham Health Plan will authorize
continuing services until one of the following occurs: - The member withdraws the BOH appeal; or
- The BOH issues an adverse decision to the member’s appeal request.
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Level I Standard Appeals
A treating provider may file a clinical appeal on behalf of a member for any decision made by Mass General Brigham Health Plan to
deny, terminate, modify, or suspend a requested health care benefit based on failure to meet medical necessity, appropriateness of
health care setting, or criteria for level of care or effectiveness of care. Punitive action will not be taken against a provider who
requests an appeal on behalf of a member.
A member appeal must be filed within 30 calendar days of Mass General Brigham Health Plan’ decision. However, a member can
continue receiving ongoing services during an appeal, as long as the appeal is requested within 10 calendar days of Mass General
Brigham Health Plan’ decision.
In order to consider an appeal filed by a third-party, Mass General Brigham Health Plan must receive written authorization from the
member designating the individual as their appeal representative. The Mass General Brigham Health Plan Designation of Appeal
Representative Form should be used for this purpose. The appeal process will not be held up pending receipt of the form.
The completed, signed, and dated form must be received prior to the deadline for resolving the appeal. Otherwise, all communication
will take place with the member.
When filing an appeal on behalf of a member, the provider must identify the specific benefit that Mass General Brigham Health Plan
denied, terminated, modified, or suspended, the original date of Mass General Brigham Health Plan’ decision and the reason(s) the
decision should be overturned. The provider may request a peer-to-peer discussion with the Mass General Brigham Health Plan
medical director involved in the Internal Appeal regarding these matters.
Appeals may be filed by telephone, mail, fax, or in person. Mass General Brigham Health Plan will send a written acknowledgment of
the appeal on behalf of a member, along with a detailed notice of the appeal process within one business day of receiving the
request.
An appeal will be conducted by a health care professional that has the appropriate clinical expertise in treating the medical condition,
performing the procedure, or providing the treatment that is the subject of the Adverse Action, and who was not involved in the
original Adverse Action.
For a standard appeal, Mass General Brigham Health Plan will complete the appeal and contact the provider with the outcome of the
review within 30 calendar days.
The time frame for a standard appeal may be extended for up to five calendar days if the member requests an extension, or if Mass
General Brigham Health Plan requests the extension having determined that it will be in the member’s best interest and there is
reasonable likelihood that receipt of more information within five calendar days would lead to an approval.
Mass General Brigham Health Plan’ Appeals and Grievances Department will make reasonable efforts to provide verbal notification of
the decision within one business day, with written notification to follow within 30 days of receipt of the appeal.
A clear description of the procedures for requesting a BOH external appeal, including enclosures of Mass General Brigham Health Plan’
Appeals Process and Rights for MassHealth members and a Request for a Fair Hearing Form are included with any denial of appeal
notice to the member.
Providers, if acting in the capacity of an authorized representative, may request that Mass General Brigham Health Plan reconsider an
appeal decision if the provider has or will soon have additional clinical information that was not available at the time the decision was
made. Upon a reconsideration request, Mass General Brigham Health Plan will agree in writing to a new time period for review. To
initiate reconsideration, contact the Appeal Coordinator:
Contact Information
Appeals and Grievances Department
Mass General Brigham Health Plan
399 Revolution Drive, Suite 820
Somerville, MA 02145
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Standard Clinical Appeals (continued)
Standard External Reviews
Once the Mass General Brigham Health Plan’ appeal options have been exhausted, members may file an appeal with the
Board of
Hearings (BOH). The exhaustion requirement is satisfied if Mass General Brigham Health Plan has issued a decision following
the Level I appeal.
BOH appeals of a standard internal appeal must be filed within 30 calendar days after the notification of decision on the
final internal appeal.
Any services that are subject of a BOH appeal will continue, pending resolution of the appeal, unless the member
specifically indicates that they do not want to receive continuing services, and the BOH receives a written request from the
member within 10 calendar days from the notification of decision on the final internal appeal. If the BOH upholds an
adverse action to deny, limit, or delay services and the member received continuing services while the BOH Appeal was
pending, the member may be financially responsible for the cost of any requested services received during this time period.
Members must complete the Request for Fair Hearing form (included with the appeal decision notification) and submit it to
the BOH. Mass General Brigham Health Plan can assist Members in completing this form.
Contact Information
Appeals and Grievances Department
Mass General Brigham Health Plan
399 Revolution Drive, Suite 820
Somerville, MA 02145
Phone: 800-462-5449 Fax:
617-526-1980
To initiate an external review, contact:
Board of Hearing (BOH) Office
of Medicaid
100 Hancock Street, 6th Floor Quincy,
MA 02171
Fax: 617-847-1204.
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Access to Appeal File by Member or Member
Representative
Members or their representative have the right to
receive a copy of all documentation used in the
processing of their appeal, free of charge. The request
must be submitted in writing to Mass General
Brigham Health Plan.
Limitations may be imposed, only if, in the judgment
of a licensed health care professional, the access
requested is reasonably likely to endanger the life or
physical safety of the individual or another person.
Requests for access to appeal files will be processed
as quickly as possible, taking into consideration the
member’s condition, the subject of the appeal, and
the time frames for further appeals.
Continuation of Ongoing Services During Appeal
If the appeal concerns the denial, modification, or
termination of covered service that the member is
receiving at the time of the adverse action, the
member has the right to continue their benefits
through the conclusion of the appeals process. There
are timeframes for requesting continuation of
coverage, as explained in the table above. Continued
authorization will not, however, be granted for
services that were terminated pursuant to the
expiration of a defined benefit limit.
If the appeal concerns the denial, modification, or
termination of a non-covered service that the
member is receiving, and Mass General Brigham
Health Plan does not reverse the adverse action, the
member may be liable for payment of the service.
Notification of Decision
If Mass General Brigham Health Plan does not act
upon an appeal within the required timeframe, or an
otherwise agreed upon extension, the appeal will be
decided in the member’s favor. Any extension
deemed necessary to complete review of an appeal
must be authorized by mutual written agreement
between the member (or an authorized
representative) and Mass General Brigham Health
Plan.
Reconsideration of Appeal Decision
Providers acting in the capacity of an authorized
representative may request that Mass General
Brigham Health Plan reconsider an appeal decision if
the provider has or will soon have additional clinical
information that was not available at the time the
decision was made. Upon a reconsideration request,
Mass General Brigham Health Plan will confirm in
writing the agreement to a new time period for
review. A reconsideration request can be initiated by
contacting the individual identified in the Mass
General Brigham Health Plan letter.
Consumer Protection from Collections and
Credit Reporting During Appeals
Massachusetts Law requires health care providers
(and their agents) to abstain from reporting a
member’s medical debt to a consumer credit
reporting agency or sending members to collection
agencies or debt collectors while an internal or
external appeal is going on. This consumer protection
also extends for 30 days following the resolution of
the internal or external appeal.
Behavioral Health Appeals
Management for all behavioral health related appeals
is delegated to Mass General Brigham Health Plan’s
Behavioral Health Partner, Optum.
For more information, please see the Behavioral
Health Provider Manual or contact Optum at
844-451-3519.
