December 2025: Prime webinar sessions added; required MOC training for SCO and One Care providers

From blood drives to companionship: Six ways to make a difference in healthcare

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 

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 

In this issue:

• Action required: Attest to your provider directory information in the Provider Portal
• Provider update: Prime webinars extended into January
• Required model of care (MOC) training for SCO and One Care providers
• InterQual 2025 update
• Provider FAQ and webinar: Dual Eligible Special Needs Plans (D-SNPs)
• Utilization Management updates – Effective January 1
• Provider Services inquiry line process change effective January 1, 2026
• Update to Provider Enrollment email requests
  
• Payment policy update: Reimbursement for Medicare Advantage annual preventive physical examinations
• New claims process for Part D vaccines when administered in a provider's office
• Meet the Provider Relations team: Beronica Robles
• Help us improve the member experience — confirm your next available appointments
  
• Select a designated Provider Portal User Administrator
• The Medicare Prescription Payment Plan helps members manage monthly drug costs
• Medicare Advantage hearing aid evaluation and fitting codes
• Help us keep directory information up to date
• Medical policy updates
• Drug code and code updates
• 2026 Medicare pharmacy updates
• Formulary updates

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.

Provider update: Prime webinars extended into January

We’re excited to share that Prime webinars will continue into January to support your ongoing learning needs. In addition, provider training slides have been uploaded to the Prime and Provider resource landing pages for your convenience.

• Provider resources
• Prime Therapeutics

Join us for a 60-minute, web-based training session presented by Prime and become familiar with:

• The policies and procedures for this new program.
• What medical benefit drugs should be submitted to Prime for prior approval.
• How to obtain access to the Prime website.
• How to complete prior authorization requests using easy-to-use online tools from Prime.

Please take advantage of this opportunity!  

It is recommended that you reserve your spot in one of these education sessions at least one week ahead of time. You will receive a registration confirmation email from Prime for the webinar session you select, including instructions for dialing in by phone should you need to do so. 

You will only need to attend one of the above educational sessions. 

Please note that you will be able to begin requesting prior authorizations beginning December 22, 2025, for dates of service on or after January 1, 2026. If you have questions, please contact Mass General Brigham Health Plan at 855-444-4647 or HealthPlanProvRelations@mgb.org. For FAQs, please visit the Prime Therapeutics resource page. 

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

The model of care training for SCO and One Care providers will be available on our provider webpage beginning January 1, 2026.

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.

InterQual 2025 update

InterQual 2025 Criteria is now in place, no substantiative changes were implemented during the 2025-year updates. 

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

Mass General Brigham Health Plan is excited to launch 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:

Utilization Management updates – Effective January 1

Provider Portal Submissions

The provider portal allows Primary Care Providers to submit notifications for specialty providers referrals in the same drop-down as a submission for prior authorizations.  This drop-down will be updated to reflect the submission type of referrals or prior authorizations more clearly.

The new hyperlink will show as Submit a referral notification or prior authorization to replace the current link that shows Submit an auth (screenshot below).

Why are we updating this: This submission type needs to be clear when Providers are submitting a request for the utilization management team to review. If you are letting MGBHP know about an in-network referral for a commercial HMO or EPO member, the referral option needs to be utilized. Specialty referrals are not required for PPO, Medicare Advantage, or Medicare balance members. Specialty referrals are also not required for in-network specialty visits for MGB ACO members.

**Note: A referral is a notification from an MGB Health Plan PCP to MGB Health Plan for in-network usage of non-emergent specialty care and is NOT a prior authorization.

See our online user guide for specialty referrals Mass General Brigham Health Plan Provider Portal

Currently our Provider Portal reflects the options below once you select Referrals and Authorizations:

The updated version will reflect a clearer list showing prior authorization options and a specialty referral notification option:

For any questions or issues regarding provider portal submissions, please contact Provider Services at 1-855-444-4647.

Provider resources | Mass General Brigham Health Plan

Provider Services inquiry line process change effective January 1, 2026

To enhance the quality of support and reduce extended hold times, effective January 1, 2026, Provider Services will implement the following process change for all lines of business:

Limit of five inquiries per call
Each call to Provider Services will be limited to a maximum of five inquiries.

Why this change?
This adjustment is designed to streamline our support process, reduce wait times, and ensure timely assistance for all providers. Please use the Provider Portal for quick and easy self-service.  

Your partnership matters
We appreciate your cooperation and continued partnership as we work to improve service delivery.

Update to Provider Enrollment email requests

As previously announced, Provider Enrollment no longer accepts email requests for the following actions:

1. Notification that a primary care provider (PCP) or an individual provider within a provider group is no longer accepting new patients for a network plan.
2. Updates to a provider’s practice location or other demographic provider directory information.
3. Notification of a provider’s retirement or termination.
4. Confirmation of provider's effective dates.

To ensure timely processing and accuracy, these requests must be submitted via our Provider Portal Mass General Brigham Health Plan Provider Portal.

We appreciate your cooperation in transitioning to this new process, which will help us serve you more efficiently.

If you have any questions or require assistance using our Provider Portal, please contact the Provider Service Center HealthPlanProvidersService@mgb.org.

Payment policy update: Reimbursement for Medicare Advantage annual preventive physical examinations

Mass General Brigham Health Plan will provide reimbursement for one annual preventive physical examination per calendar year when conducted by the member's primary care provider.

Mass General Brigham Health Plan does not reimburse:

• Annual preventive physical examinations performed by the member's OB-GYN, who is not their primary care provider, are not reimbursed under the supplemental benefit. Only Medicare-covered services should be performed and billed by the OB-GYN provider. For more comprehensive preventive care, members should be referred to their primary care provider.
• A second preventive physical examination performed within the same calendar year is not reimbursable.

New claims process for Part D vaccines when administered in a provider's office

If a member receives a Part D vaccine in a provider’s office, rather than at the pharmacy, you may now access the TransactRx application to submit Part D vaccine claims electronically to the PBM. The portal is currently available and will be required beginning January 1, 2026.

After completing a one-time online enrollment process on the TransactRx portal you can: 

• Verify a member’s eligibility and benefits in real-time 
• Advise members of their appropriate out-of-pocket cost share 
• Submit Part D vaccine claims electronically 
• Receive reimbursement information in real-time  

To get started

To learn more and enroll, please visit TransactRx at https://www.transactrx.com/enrollment.

Meet the Provider Relations team: Beronica Robles

Beronica has been an integral part of the Provider Relations team for three years and has dedicated 25 years to Mass General Brigham Health Plan. She manages the Professional Ancillary Provider network and brings a wealth of knowledge from her experience with the Customer Service Center and the overall provider network. Her expertise plays a key role in supporting our providers and helping ensure a positive experience for both internal and external customers.

If you're in Beronica's network area and would like to get in touch with her, please email brobles@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.

The Medicare Prescription Payment Plan helps members manage monthly drug costs

Mass General Brigham Health Plan offers a Medicare Prescription Payment Plan to all members. Members can choose to spread out their covered Part D out-of-pocket prescription drug costs over the calendar year. The Inflation Reduction Act requires all Medicare prescription drug plans, including standalone Medicare prescription drug plans and Medicare Advantage plans with prescription drug coverage, to offer members the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments instead of all at once at the pharmacy. This payment option is known as the Medicare Prescription Payment Plan.

The Medicare Prescription Payment Plan doesn’t lower members covered Part D drug costs or save money. However, it may be helpful for members to spread their payments for covered Part D drug costs across the remaining months of the calendar year. There’s no cost to members to participate in the Medicare Prescription Payment Plan and participation is voluntary. Members must voluntarily opt into the Medicare Prescription Payment Plan to participate. Members who are active in the Medicare Prescription Payment Plan and remain in the same Part D Plan will be automatically renewed for the following plan year. New members or members who change their Part D plan must opt into the Medicare Prescription Payment Plan each year. To maximize this payment option, members should opt-in to this payment option prior to filling their prescriptions.

Members may benefit from the Medicare Prescription Payment Plan if:

• They have high covered Part D drug costs early in the plan year.
• They will exceed the $2,100 annual out-of-pocket maximum Medicare Part D drug cost amount for 2026 before September.
• They want to spread their covered Part D drug costs throughout the rest of the year.

Members may not benefit from the Medicare Prescription Payment Plan if:

• They have low yearly out-of-pocket covered Part D drug costs (<$2,100 per year).
• They receive or are eligible for Extra Help from Medicare.
• They receive or are eligible for a Medicare Savings Program.
• They receive help paying for drugs from other organizations, like a State Pharmaceutical Assistance Program (SPAP), a coupon program, or other health coverage.
• They are in plans that exclusively charge $0 cost sharing for covered Part D Drugs.

Members may opt in during the annual election period beginning in October or may wait until the plan year to opt into the Medicare Prescription Payment Plan. However, if they would like the Medicare Prescription Payment Plan to be active January 1, then they must opt into the program during the annual election period.

Members may opt out or leave the Medicare Prescription Payment Plan at any time by contacting the health or drug plan. Leaving the Medicare Prescription Payment Plan will affect their Medicare drug coverage and other Medicare benefits.

If a member does not pay their Medicare Prescription Payment Plan bill, they’ll be removed from the Medicare Prescription Payment Plan. Members are required to pay the amount owed but will not pay any interest or fees, even if the payment is late. If a member is removed from the Medicare Prescription Payment Plan, they are still enrolled in their Medicare health or drug plan.

Medicare Advantage hearing aid evaluation and fitting codes

For Medicare Advantage members, hearing aid evaluation and fitting is a benefit offered through TruHearing. The member must see a TruHearing provider to use this benefit. Please direct the member to contact TruHearing at 888-937-2017.

Hearing aid evaluation and fitting codes:
92590 – Hearing aid examination and selection; monaural
92591 – Hearing aid examination and selection; binaural
92592 – Hearing aid check; monaural
92593 – Hearing aid check; binaural
92594 – Electroacoustic evaluation for hearing aid; monaural
92595 – Electroacoustic evaluation for hearing aid; binaural
V5010 – Assessment for hearing aid
V5011 – Fitting/Orientation/Checking of hearing aid
V5014 – Hearing aid, binaural, behind the ear
V5013 – Hearing aid, binaural, in the ear

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

Seventeen (17) medical policies were reviewed and passed by Mass General Brigham Health Plan’s Medical Policy Committee. View a summary of the 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 December 2025 here.

Medicare pharmacy updates

View updates here. 

Formulary updates

View the formulary updates here.