August 2025: Join our Quality Program Committee; register for our Provider Portal webinar

Understanding PTSD in first responders: A call for support and awareness

Every day, first responders—police officers, firefighters, paramedics, and emergency medical technicians—put their lives on the line to protect and serve their communities. They face intense, high-stress situations, such as violent crimes, medical emergencies, and natural disasters. These experiences can take an emotional toll. For some first responders, the weight of what they witness on the job can lead to Post-Traumatic Stress Disorder (PTSD), a mental health condition that affects not only their well-being but also their ability to perform their duties. Read the full article.

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

•    General provider tools and resources and/or MGBHP policies and procedures questions
•    Member benefits & coverage
•    Claim review/appeals requests
•    PCP referrals and/or prior authorization requirements
•    Medical drug specialties coverage requirements
•    Copies of relevant provider materials

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 

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

•   Benefits and cost sharing 
•   Claims status
•   Member eligibility
•   PCP changes
•   Authorization submission
•   EOP
•   And more

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

In this issue:

• Join our Quality Program Committee to help improve care quality and effectiveness
• Action required: Attest to your provider directory information in the Provider Portal (Now Live)
• Retraction of recent authorization policy update & claims reconsideration
• New MassHealth resources for providers caring for pregnant and postpartum members
• Introducing Porter Cares
• August webinar: Provider Portal overview
  
• Meet the Provider Relations team: Colleen Murphy
• AllMed to support utilization management and appeal reviews beginning Sept. 1
• Utilization Management updates – Effective Sept. 1
• Video: Submitting claims and claims reviews in the Provider Portal
• Select a designated Provider Portal User Administrator
• Help us keep directory information up to date
• Multiple procedure reduction rule, effective August 1
• Medical policy updates
• Drug code and code updates
• Formulary updates

Join our Quality Program Committee to help improve care quality and effectiveness

Mass General Brigham Health Plan is seeking provider membership (including all MD specialties, NPs, and PAs) for its Quality Program Committee (QPC) to share expertise on topics that will ensure the quality and effectiveness of the care delivered to its members including all lines of business. Committee members have the opportunity to weigh in on a variety of health plan topics including:

• Network adequacy;
• Utilization Management and Medical Necessity Procedures;
• Member experience and satisfaction; and
• Identifying and addressing potential health care disparities and inequities.

The QPC meets virtually on the third Wednesday every other month for 90 minutes. 

The meeting dates for the rest of 2025 are:

• Wednesday, August 20, 7:30 - 9 a.m.
• Wednesday, October 15, 7:30 - 9 a.m.
• Wednesday, December 17, 7:30 - 9 a.m.

If you're interested in joining the QPC, please contact Elaine Alden at ealden@mgb.org indicating your interest and we will reach out with information on next steps. Some providers may qualify to earn $300 per meeting. Feel free to contact us with any questions regarding your eligibility for this and/or any other questions.

We appreciate the opportunity to collaborate with our provider network and thank you for the care you provide our members.

Action required: Attest to your provider directory information in the Provider Portal (Now Live)

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. 

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

Retraction of recent authorization policy update & claims reconsideration

We are writing to inform you of two important updates regarding authorization policies and claims processing.

1. Retraction of recent authorization policy update

The recent policy change requiring new authorizations for the addition of CPT/HCPCS codes to existing authorizations is being retracted, effective immediately.

Due to unforeseen IT system limitations, we are currently unable to support this change operationally. As a result:

• You may continue to add new CPT/HCPCS codes to existing authorizations without submitting a new authorization.
• Revisions related to units or dates remain allowable under existing authorizations.
• The previously stated exception for IVF cancellation codes and urgent ICSI requests remains unchanged.

We are actively working to resolve these technical issues. At this time, we anticipate the policy will be reinstated no sooner than September 1, 2025.

2. Claims reconsideration for denials between May 15 – June 16, 2025

We recognize that some claims may have been denied between May 15 - June 16, 2025, due to providers being unable to submit new authorizations with updated codes during this transition.

If you experienced claim denials during this period for this reason, we are willing to reconsider those claims. Please resubmit the affected claims along with the appropriate authorization details for review.

We appreciate your understanding and continued partnership as we work to improve our systems and processes. 

New MassHealth resources for providers caring for pregnant and postpartum members

MassHealth has published a new webpage for providers caring for pregnant and postpartum MassHealth members, such as OB/GYNs, midwives, primary care providers, pediatricians, and others. It includes detailed information and resources across several topics: 

• Eligibility and covered services 
• Managed care information and supports 
• MassHealth doula benefit 
• Behavioral health 
• Breast pumps and lactation support 
• Family planning 
• Prenatal screening/diagnosis and vaccines 
• Social determinants of health (SDOH) 
• Patient-facing materials

MassHealth has also published new flyers with a checklist of important actions for pregnant members. The flyers are available to download and print in several languages on the new webpage: mass.gov/perinatalproviders.

Introducing Porter Cares

Porter is a trusted healthcare partner now working with Mass General Brigham Health Plan. Porter provides one-time in-home assessments or telehealth assessments conducted by a physician or qualified non-physician practitioner designed to complement the care provided to the patient. It is not meant to replace any existing relationship with the patient’s PCP or specialist.

Porter helps your patients navigate through their insurance benefits, schedule appointments with community providers, and access Federal, State, and local resources for additional support. These visits are designed to close care gaps, improve diagnostic accuracy, and connect patients to appropriate follow-up care and community resources. While Porter's support is often short-term and targeted, it serves as a valuable extension of the care team.

For additional information, please see our FAQs or review the in-home assessment overview deck. 

August webinar: Provider Portal overview

Join us on Wednesday, August 20 at noon for a live webinar covering the functions of our Provider Portal. During this session, we will provide an in-depth demonstration of the Provider Portal, explaining how to navigate key features such as initiating prior authorization requests, managing claims, updating data, and utilizing additional tools to support your practice. Please note, this webinar is for medical providers only.

Date: August 20, 2025
Time: 12 - 1 p.m.
Registration: CLOSED
Registered attendees will receive an email with call-in information prior to the webinar. 

Meet the Provider Relations team: Colleen Murphy

Colleen Murphy is the newest member of the Provider Relations team at Mass General Brigham Health Plan. Colleen comes to us with a wealth of knowledge from Commonwealth Care Alliance and Harvard Pilgrim. With experience in both Provider Relations and Pharmacy Relations, Colleen’s expertise includes provider network management, provider education, and work pertaining to Pharmacy Benefits Manager for insurance verifications, Medicare Part D plans, and Third Party Insurance as well as Medicaid. 

Colleen will be managing the MGB Hospitals, Physician groups, and affiliates along with DFCI.

If you're in Colleen's network area and would like to get in touch with her, please email: cmurphy119@mgb.org

CMS requirement: Submit Form CMS-2552-10 for Transplant when billing for Rev 81X

Mass General Brigham Health Plan's Medicare Advantage product line follows the CMS requirements for Transplant. The CMS requirement is as follows: Submit Form CMS-2552-10 for Transplant when billing for Rev 81X. 

AllMed to support utilization management and appeal reviews beginning Sept. 1

Mass General Brigham Health Plan will use an additional independent review organization, AllMed, starting on 9/1/2025. AllMed will be available to the plan to assist with review of cases where external subject matter expertise or same/similar specialty is necessary.

Utilization Management updates – Effective Sept. 1

We’re making several important updates to our Utilization Management processes to improve efficiency and clarity for providers. Please review the following changes:

Please note: Training will be offered in August prior to implementation.

2. Global authorizations for surgical procedures
•    Surgical authorizations will no longer be split into an authorization for the surgeon and one for the facility. One authorization will be created for both the
     surgeon and the facility
•    The submission process on the provider portal remains unchanged
•    Approval and/or adverse determination letters will now be sent to the requesting surgeon, not the facility

3. Annual reauthorization requirement for ongoing services
•    For outpatient prior authorization requests, a new prior authorization must be submitted one year from the original request date
•    Example: If the initial request for home care services was submitted on November 28, 2024, a new authorization request is required by November 27, 2025
•    This applies only to prior authorizations with no code changes

4. Provider Portal update: Service start and end dates
Please note the following update regarding the entry of service dates on the Provider Portal:

•  The service end date will be automatically populated only for the following Outpatient services:
•  Outpatient surgeries (e.g., surgical day care)
•  High-tech radiology
•  Enteral services
•  Specialty referrals
•  For all inpatient services and outpatient services not listed above, you will need to manually enter the Service End Date.

5. Provider Portal enhancement
Enhancements will be made under the Authorization/Service Lines section. You will now be able to view:
•  A description of the authorization request
•  Dates of service
•  Number of units/days approved
•  Units/days used

These updates are designed to provide greater transparency and improve tracking of authorization details.

Thank you for your continued partnership!

Video: Submitting claims and claims reviews in the Provider Portal

We’re excited to announce you can submit claims and claims reviews in the Provider Portal. When submitting a claim or claim review, a transaction number confirming receipt of submission will be available and providers can track the status of a submission within the Provider Portal. Please note, a claim review form must be completed and attached to the online claim review submission. Please review the video walkthrough of the new features below or read the overview. If you need assistance with the Provider Portal, please contact HealthPlanprweb@mgb.org.

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

Multiple procedure reduction rule, effective August 1, 2025

Mass General Brigham Health Plan updated its multiple procedure reduction rule effective August 1, 2025.

Multiple Procedure Reduction Rule: When multiple surgical procedures are performed in the same operative session, the procedure with the highest RVU will be reimbursed at 100% of the allowed amount and all subsequent, lower RVU-valued procedures, will be reduced per the Plan’s Modifiers Provider Payment Guidelines, unless otherwise specified in the provider’s contract.

Medical policy updates

Eleven (11) medical policies were reviewed and passed by Mass General Brigham Health Plan’s Medical Policy Committee. View a summary of the updates here. 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 August 2025 here. 

View the coverage summary for July 2025 new HCPCS codes here.

Formulary updates

View the formulary updates here.