January 2026: D-SNPs provider FAQs and webinar; enroll in MCPAP

Helping primary care providers approach patients’ mental health needs

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:

• Enroll in the Massachusetts Child Psychiatry Access Program (MCPAP)
• Provider FAQs and webinar: Dual Eligible Special Needs Plans (D-SNPs)
• Required model of care (MOC) training for SCO and One Care providers
• Utilization of language services report
• Annual code and rate updates
• ACO spotlight: Provider’s role in improving quality measures
• Action required: Attest to your provider directory information in the Provider Portal
• Reminder: SNF/Rehab/LTAC require prior authorization
• Primary care sub-capitation updates
• Provider update: Prime webinars extended into January
• Our new member wellness hub has arrived
• Hospital inpatient utilization report
• Utilization Management updates – Effective January 1
• Provider Services inquiry line process change effective January 1, 2026
  
• 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
• 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
• 2026 Medicare pharmacy updates
• Formulary updates

Enroll in the Massachusetts Child Psychiatry Access Program (MCPAP)

The Massachusetts Child Psychiatry Access Program (MCPAP) is a system of regional children's behavioral health consultation teams designed to help primary care providers and their practices promote and manage the behavioral health of their pediatric patients as a fundamental component of overall health and wellness. MCPAP supports the integration of behavioral and physical health. If you are a primary care provider who treats children and you would like to enroll with MCPAP, please visit their enrollment page.

MCPAP's core services include:

• Telephone consultation with either a child and adolescent psychiatrist or independently licensed behavioral health clinician
• Face-to-face consultation with either a child and adolescent psychiatrist or independently licensed behavioral health clinician when indicated
• Resource and referral
• Practice-focused training and education

Expanded MCPAP for autism spectrum disorder and intellectual disability (ASD-ID) services are now available to provide pediatric PCCs with quick access to Licensed Applied Behavioral Analysts (LABAs). This service is for youth and young adults up to age 26 who have an existing diagnosis of autism or intellectual disability and who are experiencing escalating behavioral health symptoms. 

To access this service, PCCs and Integrated behavior health clinicians should contact their usual MCPAP team. They should speak with a MCPAP consultant to discuss having an ABA initial consultation, and the MCPAP consultant will refer the family to schedule the session with the MCPAP for ASD-ID team when appropriate. A follow-up consultation with a MCPAP physician will be scheduled when needed.  

Primary care providers can learn more about MCAP and enroll in the program at mcpap.com.

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:

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.

Utilization of language services report

Below please find a report that depicts language services completed at each affiliated medical facility between December 2024 and November 2025. The majority of language services completed were for the following languages:

For the full list of language service requests, please view this report. Data is provided by LanguageLine Solutions.

Mass General Brigham Health Plan provides language cards to assist members with identifying their preferred language. These can be found on the Mass General Brigham Health Plan website under Provider Resources: Provider resources | Mass General Brigham Health Plan.

Annual code and rate updates

Mass General Brigham Health Plan reviews its 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.

Consistent with prior years, Mass General Brigham Health Plan will update its Commercial/PPO physician, ambulance, drug, DME, laboratory, radiology, and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2026.  Rate updates to existing CPT and HCPCS codes will occur on July 1, 2026.

With a few exceptions, Mass General Brigham Health Plan will continue to base fees on the Centers for Medicare & Medicaid Services (CMS) and MassHealth fee schedules, adjusted to achieve the contracted level of reimbursement.

Commercial/PPO physician fee schedules

• Mass General Brigham Health Plan will continue to base physician reimbursement on CMS RVU’s.
• Mass General Brigham Health Plan will continue to base drug, vaccine, and toxoid reimbursement on CMS Part B levels, as indicated on the CMS Part B drug quarterly notices. If no CMS pricing is available, drug pricing will be set in relation to average wholesale price (AWP). Reimbursement for vaccines and toxoids will continue to be updated on a quarterly basis.

Commercial/PPO outpatient fee schedules

• Consistent with prior years, reimbursement will be based on a combination of outpatient, ancillary, and surgical fee schedules.
• Mass General Brigham Health Plan will continue to base drug, vaccine, and toxoid reimbursement on CMS Part B levels, as indicated on the CMS Part B drug quarterly notices. If no CMS pricing is available, drug pricing will be set in relation to average wholesale price (AWP). Reimbursement for vaccines and toxoids will continue to be updated on a quarterly basis.

Medicaid ACO fee schedules

• Mass General Brigham Health Plan will continue to base physician reimbursement on MassHealth published rates.
• Consistent with prior years, Mass General Brigham Health Plan will update its Medicaid physician, ambulance, drug, DME, laboratory, radiology, and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2026.  Rate updates to existing CPT and HCPCS codes will occur within 30 days of receipt of notification of rate changes from MassHealth.

Medicare Advantage fee schedules

• Mass General Brigham Health Plan will update its Medicare Advantage inpatient, outpatient, ancillary, professional, DME, and drug fee schedules/pricers to incorporate new codes and update rates, effective January 1, 2026.  

ACO spotlight: Provider’s role in improving quality measures

At Mass General Brigham Health Plan, the Quality Department spearheads performance improvement for the ACO Quality Measures that are part of the MassHealth AQEIP and the National Committee of Quality Assurance (NCQA).

For the January edition, the Quality Department has provided HEDIS Tip Sheets for the following quality measures: Childhood Immunization Status (CIS), Immunizations for Adolescents (IMA), Statin Therapy for Patients with Diabetes (SPD), and Statin Therapy for Patients with Cardiovascular Disease (SPC).

As a provider there are many opportunities to impact HEDIS® measures. This includes educating parents and caregivers on the importance of childhood and adolescent vaccinations, scheduling follow-up appointments, coordinating care, using correct diagnosis and procedure codes, and educating patients on the importance of taking their medications regularly and as prescribed.

Click on the links below to see Provider Tips on how you can help improve the Quality Measures.

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.

Primary care sub-capitation updates

MassHealth made an update to the sub-capitation excluded specialties list for 1/1/2026, and both Nurse Midwife and OB/GYN are now excluded. The Mass General Brigham ACO Primary Care Sub-Capitation Resource Guide has been updated to reflect this change.

Reminder: SNF/rehabilitation/LTAC require prior authorization for ACO members

Please note that skilled nursing facility, rehabilitation, and long-term acute care services require prior authorization for ACO members. For additional information, please review the following resources:

• Prior authorization guide
• Skilled nursing facilities provider payment guidelines
• Extended care facility medical policy

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. 

Our new member wellness hub has arrived

We are pleased to share that Mass General Brigham Health Plan's new member wellness hub is now live!

Our previous health and wellness platform provided by Personify Health has been replaced by a new and improved Mass General Brigham Health Plan wellness hub. Building on our suite of digital tools, the enhanced platform helps members set personalized health goals, choose activities that match interests and well-being needs, and join challenges to build healthy habits. A refreshed health profile questionnaire is available to complete in the new hub, which is accessible through our Member Portal at Member.MGBHP.org.

Members with existing accounts on the current Personify Health wellness platform received an email alerting them to the change. We're so excited for our members to explore the new Mass General Brigham Health Plan wellness hub in 2026.

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.

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 we're 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 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.

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.

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

Nine (9) 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 January 2026 here.

Medicare pharmacy updates

View updates here. 

Formulary updates

View the formulary updates here.