April 2026: MassHealth RY25 encounter data deadline; hospital inpatient utilization report

Understanding the spectrum of autism: A clear, compassionate guide

Contact

MGBHP Provider Service Team can assist our provider network with inquiries and status requests, including the following:

•    General provider self-service tools access questions
•    Member benefits and coverage inquiries
•    MGBHP policies and procedural questions
•    Claim adjudication questions

Phone: 855-444-4647
Email: HealthPlanProvidersService@mgb.org 

MGBHP Provider Relations works in partnership with provider offices to build and maintain positive working relationships, respond to the needs of contracted providers, and assist with any training and education. Provider Relations can also assist with escalations. 
Email: HealthPlanProvRelations@mgb.org 

SCO and One Care Provider Relations works in partnership with contracted SCO and One Care provider offices to foster and sustain collaborative working relationships, address the needs of providers, and support any training and education needs. SCO and One Care Provider Relations can assist with escalations.
Email: HealthPlanSCOandOneCareProvRelations@mgb.org

Provider Portal: Register for the portal to complete the following tasks:

•   Benefits and cost sharing 
•   Claims status
•   Member eligibility
•   PCP changes
•   Authorization submission
•   Explanation of Payment (EOP)
•   And more

Register and access the portal here: Provider.MGBHP.org 

Utilization Management: To support timely and accurate responses to Utilization Management (UM) related questions, please use the designated communication channels outlined below. 

Phone: 855-444-4647
Email: MGBHPInquiryUM@mgb.org

In this issue:

• ACO update: Provider appeals limited to Level I effective April 28, 2026 – Additional clarification
• Mass General Brigham Health Plan Supplier Diversity Program (SDP)
• EOP Appeals language update
• Update: MassHealth RY25 encounter data deadline is July 30, 2026
• Important update: MassHealth ending BH and LTSS Community Partners Program
  
• Provider FAQs and webinar: Dual Eligible Special Needs Plans (D-SNPs)
• Required model of care (MOC) training for SCO and One Care providers
  
• April utilization management updates
• Hospital inpatient utilization report
• Medicare Advantage FQHC Billing – Reminder
• Action required: Attest to your provider directory information in the Provider Portal
  
• Help us improve the member experience — confirm your next available appointments
  
• Select a designated Provider Portal User Administrator
• Help us keep directory information up to date
• Medical policy updates
• Drug code and code updates
• Medicare pharmacy updates
• Commercial pharmacy updates
  
• MassHealth pharmacy updates

ACO update: Provider appeals limited to Level I effective April 28, 2026 – Additional clarification

As communicated in the February Provider Newsletter, beginning April 28, 2026, providers will be limited to submitting Level I appeals for denials. Level II appeals will no longer be accepted, and if submitted, will result in a dismissal letter. For additional details, please refer to the Mass General Brigham ACO Provider Manual.

Additional clarification from the Appeals Team:
This change applies only to post-service claim disputes, which are considered provider disputes.There are no changes to pre-service requests or member appeals.

Mass General Brigham Health Plan Supplier Diversity Program (SDP)

The Mass General Brigham Health Plan Supplier Diversity Program (SDP) has been created to promote equitable procurement practices by ensuring that diverse suppliers—including minority-owned, women-owned, veteran-owned, and other disadvantaged businesses—are actively considered and engaged in all sourcing activities.

This initiative supports the plan's commitment to diverse supplier selections with the objective of achieving and fostering greater supplier diversity.

The Massachusetts Executive Office of Health and Human Services (EOHHS) website dedicated to certifying/recertifying diverse suppliers can be found here: Certification Program for SDO | Mass.gov

EOHHS Diverse Certification Categories are defined as a business which is at least 51% owned, operated, and controlled daily by one or more (in combination) American citizens of the following ethnic minority and/or gender (e.g. woman-owned) and/or military veteran classifications: 

• MBE - Minority Business Enterprise
• WBE - Woman Business Enterprise
• M/WBE - Minority and Woman Business Enterprise
• SDVOBE - Service-Disabled Veteran-Owned Business Enterprise
• VBE - Veteran-Owned Business Enterprise
• M/NPO - Minority Non-Profit Organization
• W/NPO - Women Non-Profit Organization
• M/W/NPO - Minority and Women Non-Profit Organization
• DOBE - Disability-Owned Business Enterprise
• LGBTBE - Lesbian, Gay, Bisexual, or Transgender Business Enterprise

Benefits of being certified as a Massachusetts Diverse Supplier through the EOHHS Supplier Diversity Office (SDO):

• Competitive advantages: Access to exclusive contracts, enhanced visibility in supplier databases, and specialized networking opportunities.

• Increased opportunities: The SDO’s goals include increasing diverse and small business spending through annual state agency spending benchmarks.

• Increased marketability: Diverse suppliers can enhance their marketability when bidding on public contracts. The SDO connects certified diverse businesses with business opportunities and resources that can help them grow and thrive.

• Support for underrepresented groups: Supplier diversity initiatives support underrepresented groups, such as Black, Latino, and LGBTQ+ individuals, who often face significant hurdles in accessing capital and contracting with the state.

• Economic prosperity: Supplier diversity drives financial returns, fosters innovation, enhances brand loyalty, and contributes to social and environmental impact.

Sign up today: Certification Program for SDO | Mass.gov

EOP Appeals language update

The Appeals section of the EOP has been updated to reflect more accurately the appeals process for each of the lines of business. The language now falls in alignment with the Provider Manual. Updated language is below:

Administrative Appeals Commercial and Medicaid Providers

1.Claim Request Review Process

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 portal or mailbox within 90 days of the EOP (Explanation of Payment) /Payment 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.

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.

2. Requesting an Administrative Appeal

If the provider is not satisfied with the decision, an appeal can be submitted to Mass General Brigham Health Plan’s Provider Appeals Department. Appeal requests must be submitted in writing within one of the following timeframes: 90 days from original Explanation of Payment (EOP)/Payment Date on 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.

All administrative appeals are reviewed with 60 calendar days from the receipt of the request.

Mass General Brigham Health Plan
Attn: Provider Disputes
399 Revolution Drive
Suite 810
Somerville, MA 02145

Contracted Medicare, OneCare and Senior Care Options Providers-Provider Dispute Process

Provider can submit a ‘Request for Claim Review Form’ which is available by signing in tothe Provider portal https://provider.massgeneralbrighamhealthplan.org, Claims landing page https://massgeneralbrighamhealthplan.org/providers/claims or provider manual to dispute claims payments. The preferred method of submission is via the provider portal https://provider.massgeneralbrighamhealthplan.org. Other methods of submission include mail and fax.

Mass General Brigham Health Plan
Attn: Provider Disputes
399 Revolution Drive
Suite 810
Somerville, MA 02145
Fax number: 617-526-1902

Non-Contracted Medicare, OneCare and Senior Care Options Providers

If a claim is partially or fully denied for payment, a non-contracted provider must request reconsideration of the denial within 65 calendar days from the remittance notification date. When submitting the reconsideration of the denial of payment of a signed Waiver of Liability form must be included. You can locate this form at: https://www.cms.gov/medicare/appeals-and-grievances/mmcag/downloads/model-waiver-of-liability_feb2019v508.zip

The Purpose of this Waiver of Liability form is to hold the enrollee harmless regardless of the outcome of the appeal. With the appeal, the non-contracted provider should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the providers request for reimbursement. Please submit your appeal in writing to:

Mass General Brigham Health Plan
Attn: Appeals
399 Revolution Drive
Suite 850
Somerville, MA 02145

Update: MassHealth RY25 encounter data deadline is July 30, 2026

MassHealth has communicated to all plans that 2025 claims must be adjudicated by July 30, 2026. This means all providers must submit claims with a
2025 date of service no later than July 1, 2026, to meet this adjudication deadline. If there are questions or concerns about your 2025 claims, please contact Customer Service or your designated Provider Account Executive.

Important update: MassHealth ending BH and LTSS Community Partners Program

MassHealth has announced that, as part of broader program and funding changes, the Behavioral Health (BH) and Long-Term Services and Supports (LTSS) Community Partners (CP) Program will conclude effective June 30, 2026.

Below are the key operational details:

• • Program end date: All patients enrolled in the CP program will be automatically disenrolled effective June 30, 2026.
  • Continuation of services: With the exception of natural attrition, currently enrolled patients will continue receiving CP services through June 30, 2026.
    • New enrollments closed: Effective March 1, 2026, no new Community Partners enrollments may be submitted.
        ◦ This includes referrals previously intended for a March 1 enrollment date.
      ◦ The Community Partners team will send confirmation regarding referrals that cannot be processed.
  • Patient communications: MassHealth is developing a coordinated communication strategy, including outreach to patients. Materials will be shared as soon as they are available.
  • Ongoing collaboration: Mass General Brigham Health Plan is actively coordinating with Community Partners organizations to plan for transition and continuity of care.

We recognize that this change will have a significant impact on patients who rely on Community Partners for behavioral health and LTSS coordination. Our teams are working to identify alternative resources and support pathways to mitigate disruption.

We will continue to share updates as additional guidance becomes available from MassHealth.

Meet the Provider Relations team: Tad Lawton

We're excited to spotlight Tad Lawton, who joined Mass General Brigham Health Plan in March 2025 and brings a remarkable 28 years of experience in the Managed Health Care industry. Tad’s career began with Tufts Health Plan, and over the past 12 years, he has specialized in Provider Relations, consistently making a positive impact along the way. Before coming to Mass General Brigham Health Plan, Tad worked at UnitedHealthcare, focusing on the SCO and One Care divisions—expertise that has already proven invaluable to our team.

Since his arrival, Tad has enthusiastically contributed to building a stronger plan for Mass General Brigham Health Plan, sharing his deep knowledge of SCO and One Care, and helping us cultivate a dynamic Provider Relations Team. His leadership and dedication are truly making a difference as we continue to grow and innovate.

Beyond the office, Tad enjoys capturing the beauty of the outdoors through photography, relaxing on Nantucket Island, hitting the golf course, and perfecting his sourdough bread recipes. Please join us in welcoming Tad to the team and celebrating the passion and expertise he brings to our community.

Provider FAQs and webinar: Dual Eligible Special Needs Plans (D-SNPs)

Mass General Brigham Health Plan launched SCO and One Care Dual Eligible Special Needs Plans (D-SNPs) starting January 1, 2026 across eight Massachusetts counties. To support our provider partners, we’ve created a comprehensive Provider FAQ that outlines key features, benefits, enrollment processes, billing guidance, and support contacts.

In addition, please join us for our Dual Eligible Special Needs Plans (D-SNPs) program overview webinar. This session will provide a comprehensive overview of the D-SNPs program, including key updates, eligibility criteria, and how it impacts our provider network. Whether you're new to the program or looking for a refresher, this is a great opportunity to gain valuable insights and ask questions.

Choose the session that works best for your schedule:

Required model of care (MOC) training for SCO and One Care providers 

The model of care training for SCO and One Care providers is available and can be completed on our provider resources or Dual Eligible Special Needs Plans (D-SNPs) webpages.

This training is a CMS requirement and must be completed and attested to once per year by all providers contracted with Senior Care Options (SCO) and One Care. If you have any questions, please contact your Provider Relations Representative or email us at: HealthPlanSCOandOneCareProvRelations@mgb.org.

Thank you for your continued partnership and commitment to providing high-quality care to our members.

April utilization management updates

Reminder: Formal peer to peer is not an option for ACO/Medicaid, Medicare Advantage, or DSNP. After an approval or denial has been finalized, the next step would be to submit an appeal prior to services being rendered.

Reminder: If your member does not have an out of network benefit, please direct your member to an in-network provider or facility, when possible. Out of Network requests for limited network plans will likely be denied if an in-network provider is available.

Process enhancement prior authorization revisions

• Prior authorization revisions will no longer be accepted for services other than inpatient. When an authorization request has been approved or denied for a service, units, and episode of care the authorization will be locked and considered final.
• Should you need to extend the time frame, please send that inquiry to MGBHPInquiryUM@mgb.org.
• A new authorization will need to be entered for additional services, units, and episodes of care.
• This will enable more accurate tracking for the providers, ensuring requests align with claims submissions.
• This change will go-live June 2026.

Process enhancement Home Health Authorization

• Home Health Authorization efficiencies will be deployed to decrease administrative burden for providers and streamline tracking of authorizations.

• All home health services will be consolidated into one authorization for a streamlined approach to decision making and tracking.
• Within the Home Health selection, each service will now be available for selection at the service line level with appropriate units and date spans available for
  request submission, multiple services can be selected simultaneously.
• This will enable the provider to view the authorization for the member holistically and more accurately track units and episodes of care as well as streamline
  the authorization process.
• This change will go-live June 2026.

Process clarification retrospective changes

• Retrospective modifications to decisioned (approved or denied) authorizations cannot be processed.
  
• Units, codes, or services cannot be added to an authorization that has received medical necessity review and approval or denial.
• For services requiring prior authorization, the request must be received and decisioned (approved or denied) prior to the provision of services.

Communication clarifications

• • • To support timely and accurate responses to Utilization Management (UM) related questions, please use the designated communication channels outlined below:
      ○ Phone: 855-444-4647
      ○ Email: MGBHPInquiryUM@mgb.org

Hospital inpatient utilization report

The latest quarterly hospital inpatient utilization report is now available. To review this report, click on the "Reports" tab in the Provider Portal and select "Clinical Reports." If you do not have access to the Provider Portal, you may register here.

Medicare Advantage FQHC Billing – Reminder

As a reminder, Federally Qualified Health Centers (FQHCs) billing Medicare Advantage must follow CMS billing guidelines and Mass General Brigham Health Plan payment policies. Recent claim reviews indicate that some submissions do not align with these requirements.

To support correct billing, please review the following resources:

Medicare Advantage FQHC/RHC billing guide

Provider payment guidelines: Community health centers

For questions or additional support, please reach out to Provider Relations.

Action required: Attest to your provider directory information in the Provider Portal 

In compliance with Massachusetts law and the federal No Surprises Act, health insurance plans are required to keep provider directories current. To meet these broad provider directory requirements, Mass General Brigham Health Plan requests your assistance in verifying your information in the provider directory. 

If you have an established process with CAQH, please continue utilizing that process, and we will receive your updates through that channel. It is essential, as part of the DOI initiative, to ensure all information remains current. 

For facilities and groups, please visit the Provider Portal, where you can review, update, and attest to your information. Only a User Administrator can attest to this information. Every 90 days the User Administrator will be prompted to complete the attestation. If you need access to the Provider Portal, please register here. 

Please note: Any provider not verified within 90 days will display the disclaimer below in our directory until verification is complete.

If you have any questions, please contact Provider Relations at HealthPlanProvRelations@mgb.org.

Help us improve the member experience — confirm your next available appointments

Please take a few minutes to complete this brief survey. Completing this survey will help keep our members informed of the most up to date information on when they can expect to be seen by your practice. 

Select a designated Provider Portal User Administrator

Please ensure your practice has a designated User Administrator for the Mass General Brigham Health Plan Provider Portal. The User Administrator is responsible for managing user requests for your practice and will be required to attest to your practice information via the Provider Portal. Designating a User Administrator will ensure timely access for registered users to utilize the Provider Portal.

Please complete and email the User Administrator form to HealthPlanProvRelations@mgb.org. The User Administrator will need to register for an account on the Provider Portal if they do not already have one. Please see additional helpful information on how to register for the Provider Portal below. 

Frequently asked questions about the Provider Portal

Q: How do I register for the portal?
A: It only takes about five minutes to register for the Provider Portal. Have your practice's tax ID number handy before you start.

• Register now
• Access requests are managed by the User Administrator for your practice. Contact your User Administrator if you have any questions.

Q: How do I become an administrator?
A: Please complete the User Administrator form. When your portal account is activated, you can request User Admin access under the Manage Account link on the portal home page.

Q: How do I contact customer support for the Provider Portal?
A: For registration support, technical issues, or other questions and concerns, contact HealthPlanprweb@mgb.org.

Q: What do I do if my account or password expires?
A: Your login credentials will expire and be deleted if you do not log in for 180 consecutive days. If your account is deleted, you will be required to re-register.

If you forget your password, you can reset it by clicking the "I Forgot My Password" link within the Provider Portal login page. You will be asked to provide a contact phone number and answer a security question.

Q: Who do I contact with questions regarding the Provider Portal?
A: You can contact HealthPlanprweb@mgb.org.

Help us keep directory information up to date

The Centers for Medicare & Medicaid Services and other regulatory bodies, as well as the federal No Surprises Act of 2021, require health plans to maintain and update data in provider directories. We rely on providers to review their data and notify us of changes as they happen to help ensure members have access to accurate information.

Provider demographic information in our Provider Directory must reflect accurate data at all times and should mirror the information members may receive directly from the practice or via patient appointment call centers.

On at least a quarterly basis, providers should review and verify the accuracy of their demographic data displayed in our Provider Directory, including:

• Address
• Panel status (open or closed) for each individual provider
• Institutional affiliations
• Phone number
• Other practice data

Change requests should be reported via the Mass General Brigham Health Plan Provider Portal Provider.MGBHP.org or by submitting a Provider Change via the Provider-Enrollment-Form to Mass General Brigham Health Plans Provider Enrollment Team by email at HealthPlanPEC@mgb.org.

If Mass General Brigham Health Plan identifies potentially inaccurate provider information in the directory, we may reach out to your practice to validate or obtain accurate information. 

In addition, please keep the following in mind:

• Practice location — As new providers join your practice, it is important that only practice locations where the provider regularly administers direct patient care are submitted for inclusion in the Mass General Brigham Health Plan provider directory. Locations in which a provider may occasionally render indirect care — such as interpretation of tests or inpatient-only care — should be specified to ensure the location information is included in the provider’s demographic profile, but not in the provider directory.
• Timely notice — As a reminder, notification of address, acceptance of new patients, provider terminations, and other demographic information changes should be submitted at least 30 days in advance.

For questions, contact our Provider Service Center at 855-444-4647 or Provider.MGBHP.org.

Medical policy updates

Thirteen (13) medical policies were reviewed and passed by Mass General Brigham Health Plan’s Medical Policy Committee. View a summary of the medical policy updates. These policies are now posted to MGBHP.org.

For more information or to download our medical policies, go to MGBHP.org/providers/medical-policies and select the policy under the medical policy listings.

Drug code and code updates

View code updates for April 2026

Medicare pharmacy updates

View updates here. 

Commercial pharmacy updates

View updates here. 

MassHealth pharmacy updates

No updates this month.