August 2026: Plan receives Health Outcomes Accreditation for commercial plans by the NCQA

Independence through support: A more inclusive approach to health care

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 (Senior Care Options) 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:

• Register now: Care management webinar on September 23
• Mass General Brigham Health Plan receives Health Outcomes Accreditation for commercial plans by the NCQA
• Provider webinar topic suggestion form
  
• Required model of care (MOC) training for SCO and One Care providers
  
• Important update: Temporary pause on new HRSN Supplemental Service referrals
• Prime update: Post‑Service Claim Edit (PSCE) program
  
• Mass General Brigham Health Plan Supplier Diversity Program (SDP)
• Mass General Brigham Health Plan’s drug fee schedules to be updated
• Find out how our Medicare Advantage team can support you and your patients
• Provider FAQs and recorded webinar: Dual Eligible Special Needs Plans (D-SNPs)
  
• 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

Register now: Care management webinar on September 23

Please join the Mass General Brigham Health Plan Provider Engagement team for an educational webinar focused on our care management program and how it supports providers and members. Please note, this webinar is specific to Medicare Advantage.

Date: Wednesday, September 23
Time: 10-11 a.m. ET
Link: Register here

During this session, we will discuss:

• What care management means at Mass General Brigham Health Plan.
• The core principles of Mass General Brigham Health Plan Medicare Advantage Care Management.
  
• Care management programs available to members.
• How care management supports providers.

This webinar will provide valuable insights into the services available to your patients and highlight opportunities for collaboration between your practice and our Care Management team.

Mass General Brigham Health Plan receives Health Outcomes Accreditation for commercial plans by the NCQA

Mass General Brigham Health Plan has received Health Outcomes Accreditation for our Commercial plans by the National Committee for Quality Assurance (NCQA).

NCQA’s Health Outcomes Accreditation recognizes organizations that lead the market in providing accessible and culturally or linguistically appropriate care and services through standardized data and measurement that help identify population needs and address differences in outcomes, experience, and access.

“Mass General Brigham Health Plan is committed to advancing health equity to address social determinants of health and reduce health disparities,” said Reagan Gargasz, Senior Director of Clinical Operations, Mass General Brigham Health Plan. “We are proud to be recognized by NCQA for using data to better understand our members’ health needs and support access to high-quality, equitable care. We are grateful to the many teams whose dedication and collaboration helped make this achievement possible.”

Mass General Brigham Health Plan is one of 51 commercial health plans in the country to achieve this accreditation by the NCQA. For more information about the Health Outcomes Accreditation, visit the NCQA website.

Provider webinar topic suggestion form

We welcome suggestions for webinar topics for a future provider webinar. Please share your ideas for subjects you’d like us to cover so we can tailor the content to your needs. When you’re ready, please take a moment to complete the form below.

Provider webinar topic suggestion form

We appreciate your input and are committed to offering ongoing educational opportunities that align with your interests.

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 SCO (Senior Care Options) 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.

Important update: Temporary pause on new HRSN Supplemental Service referrals

MGB ACO will temporarily pause new referrals to Health Related Social Needs (HRSN) Housing and Nutrition Supplemental Services effective August 1, 2026, as it approaches its available funding threshold for the contract year. This action is being implemented in accordance with MassHealth guidance. Importantly, patients currently receiving HRSN Supplemental Services will continue to receive approved services without interruption, and MGB ACO's broader efforts to identify and address social needs through care teams will continue.

As part of the pause on new referrals, MGB ACO and our contracted HRSN Providers must pause new referrals for any enrollees who are not currently receiving HRSN Supplemental Services. This pause applies to HRSN Housing and Nutrition Supplemental Services currently offered by MGB ACO: Housing Search, Housing Navigation, Transitional Goods, Medically Tailored Home Delivered Meals, Medically Tailored Food Boxes, Medically Tailored Food Prescriptions and Vouchers, Nutrition Education, and Nutrition Counseling.

The pause on new referrals for HRSN Supplemental Services will be subject to the following terms:

• This pause will apply to HRSN Housing and Nutrition Supplemental Services.
• This pause will apply only to referrals for enrollees who are not currently receiving HRSN Supplemental Services through MGB ACO.
• This pause will not apply to HRSN Supplemental Services currently being provided. Enrollees currently receiving HRSN Supplemental Services may continue to receive those services without interruption, including as a result of an updated determination that the enrollee continues to meet the criteria to receive that HRSN Supplemental Service.
• This pause will not apply to new HRSN Supplemental Services for an enrollee currently receiving other HRSN Supplemental Services. Enrollees currently receiving HRSN Supplemental Services may be referred to new HRSN Supplemental Services if they are determined to meet the criteria for that HRSN Supplemental Service.

Please note that this pause applies to HRSN Supplemental Services only. It does NOT apply to the so-called HRSN Required Services, which are:

• Specialized Community Support Program for Homeless Individuals (CSP-HI)
• Specialized Community Support Program Tenancy Preservation Program (CSP-TPP)
• Specialized Community Support Program for Individuals with Justice Involvement (CSP-JI)
• Homeless Medical Respite Services (HMRS)

For enrollees newly referred to HRSN Supplemental Services during the pause on new referrals, the MGB ACO HRSN team will refer them to internal teams who may be able to address Health Related Social Needs.

We understand that this change will impact plan enrollees, as well as our dedicated care teams, partners, and HRSN Providers. MGB ACO is committed to supporting all stakeholders throughout this transition and will continue to assist enrollees in identifying available alternative resources and supports to meet their housing and nutrition needs.

We will notify you again when we are able to resume new referrals for HRSN Supplemental Services.

Thank you for your understanding and continued partnership. Please contact MGBHRSN@mgb.org with any questions.

Prime update: Post‑Service Claim Edit (PSCE) program

At Mass General Brigham Health Plan, we value our partnership with you and your role in delivering high‑quality care to our members. We are writing to share information about an update to our claims review process for select medical benefit drugs.

In collaboration with Prime Therapeutics, we will be implementing a Post‑Service Claim Edit (PSCE) program for select physician‑administered drugs billed under the medical benefit effective October 1, 2026.

The PSCE program applies automated claim edits after submission to support consistent claim evaluation based on established clinical criteria. Depending on the drug, claims may be evaluated for eligible diagnosis, dosage or units, frequency or duration of therapy, loading doses, and drug waste (JW modifier), when applicable.

No changes to standard claim submission processes are required. Providers should continue submitting claims according to existing health plan requirements.

For additional information, view the PSCE frequently asked questions section on our Prime resource page. Support is available through the Prime Therapeutics Medical Pharmacy Solutions Provider Relations team at ProviderInquiry@PrimeTherapeutics.com.

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

Mass General Brigham Health Plan’s drug fee schedules to be updated

Mass General Brigham Health Plan reviews its drug fee schedules quarterly, to ensure that they are current, comprehensive, and consistent with industry standards, to the extent supported by its systems. In most cases, changes involve adding fees for new or existing codes, to supplement the fees already on the fee schedule.

The next update will occur on October 1, 2026. Changes may involve both new and existing CPT and HCPCS codes and will include the planned quarterly update to physician administered drugs, immune globulin, vaccine and toxoid fees.

Find out how our Medicare Advantage team can support you and your patients

Pictured: Informational table at the Mass General Brigham Health Care Centerin Westwood taken with Paul Connor, Field Sales Executive, Medicare Advantage and Shonda Sumpter, Practice Administrator.

The Mass General Brigham Health Plan Medicare Advantage team is here to support your practice and help your patients better understand their coverage options. Our Medicare Advantage (MA) plans are designed to enhance care coordination and provide added value for eligible patients.

Our team includes inside sales specialists, field executives, and a provider engagement manager, all focused on increasing awareness and strengthening collaboration across our network. We host webinars for providers to discuss Medicare topics and keep the network informed about key programs and updates.

How we can support your office and patients:

• Host information tables across all medical sites
• Answer questions about Medicare and our Medicare Advantage plans
• Provide one-on-one support for patients and caregivers
• Offer educational webinars to keep providers informed on product updates, Medicare changes, and important initiatives

These in-person touchpoints are especially helpful during the Annual Enrollment Period (AEP) and Open Enrollment Period (OEP), when patients are evaluating their coverage options. The provider webinars are also helpful as they keep providers informed and updated. Please keep an eye out for webinar registrations in our monthly Mass General Brigham Health Plan provider newsletter.  

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

Mass General Brigham Health Plan launched SCO (Senior Care Options) 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.

If you were unable to attend one of our live webinar sessions or would like to rewatch it, a recorded version is available below and has been added to our
provider resources page for on-demand viewing. View the slide deck here.

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

Nineteen (19) 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 the code updates for August 2026.

• View July 2026 code updates for Medicare Advantage.

• View July 2026 code updates for One Care and Senior Care Options (SCO).

• View July 2026 code updates for commercial plans.

• View the coverage summary for July 2026 new drug codes.

Medicare pharmacy updates

No updates.

Commercial pharmacy updates

View updates here. 

MassHealth pharmacy updates

View updates here.