July 2026: Required MOC training for D-SNP providers; Prime update

Digital equity for all ages: Helping older adults access technology and 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:

• Required model of care (MOC) training for SCO and One Care providers
• Prime update: Post‑Service Claim Edit (PSCE) program
  
• Provider billing reminder for D-SNPs
• Provider webinar topic suggestion form
• Find out how our Medicare Advantage team can support you and your patients
• Important notice: Change in EIBI administration 
• MassHealth RY25 encounter data deadline is July 30, 2026
• Annual updates to physician and outpatient fee schedules
• 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

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.

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.

Additional information, including drug lists and policies, will be provided in future newsletters. Support is available through the Prime Therapeutics Medical Pharmacy Solutions Provider Relations team at ProviderInquiry@PrimeTherapeutics.com.

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.

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 billing reminder for D-SNPs

As a reminder for participating providers in Mass General Brigham’s SCO and One Care networks, SCO and One Care members are dually eligible individuals for both Medicare and Medicaid. Per contractual obligations, a participating provider may not bill a SCO or One Care member for in-network covered services and/or authorized services, which includes any potential deductibles, coinsurance, or copays.

Network providers must always bill MGBHP for covered services and we will cover the cost of the services. Members are under no obligation to pay you for any perceived cost sharing and are explicitly told to not pay you. For Medicare services, when MGBHP covers the cost of the service you will receive two payments from us: one that covers the Medicare portion of the bill and the other that covers the cost sharing portion of the bill. For Medicaid services, when MGBHP covers the cost of the service you will receive one payment from us.

If you incorrectly bill a member for Medicare services and they pay you, then MGBHP will work to reimburse that member directly. If however, you incorrectly bill a member for Medicaid services and they pay you, then it is your obligation to refund the member for any payment made.

It is critically important that you do not bill SCO and One Care members for any in-network covered services and/or authorized services. If there are any questions about this important billing practice, please reach out to your Provider Relations representative at 855-444-4647 or email us at HealthPlanDSNPProvider@mgb.org.

Important notice: Change in EIBI administration

Beginning July 1, Early Intensive Behavioral Intervention (EIBI) services will move from Mass General Brigham Health Plan to Optum Behavioral Health. Optum will manage the EIBI benefit, provider network, and claims. Mass General Brigham Health Plan will retire its EIBI policy effective July 1, 2026, and an equivalent medical policy by Optum will be in place effective July 1, 2026. 

This change does not affect Early Intervention (EI) benefits or therapies such as physical, occupational, or speech therapy, which will continue as usual with Mass General Brigham Health Plan.

If you have questions, please review our joint provider frequently asked questions (FAQ) or contact our Provider Relations team at HealthPlanProvRelations@mgb.org.

Thank you for your continued partnership and support of our members.

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.

Annual updates to physician and outpatient fee schedules

Mass General Brigham Health Plan reviews its physician and outpatient fee schedules quarterly, to ensure 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 updated its Commercial, PPO, and Medicare physician, ambulance, drug, DME, laboratory, radiology, and outpatient hospital fee schedules to incorporate new codes, effective January 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

• • Rate updates to existing CPT and HCPCS codes will occur on July 1, 2026.
  • Mass General Brigham Health Plan will continue to base physician reimbursement on CMS RVU’s & anesthesia conversion factor.
  • 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.
  • Mass General Brigham Health Plan will continue to base DME reimbursement on the CMS DME POS/PEN fee schedules.

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.
  • Mass General Brigham Health Plan will continue to base DME reimbursement on the CMS DME POS/PEN fee schedules.

MGB ACO fee schedules

• • Mass General Brigham Health Plan will continue to base physician reimbursement on MassHealth published rates, where they exist.
  • Consistent with prior years, Mass General Brigham Health Plan updated 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 change from MassHealth.

Medicare Advantage fee schedules

• • Mass General Brigham Health Plan updated its Medicare Advantage inpatient, outpatient, ancillary, and professional fee schedules/pricers to incorporate new codes and update rates, effective January 1, 2026. Mass General Brigham Health Plan updates its Medicare Advantage fee schedules as directed by CMS.

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 drug code updates for July 2026.

Medicare pharmacy updates

No updates.

Commercial pharmacy updates

View updates here. 

MassHealth pharmacy updates

No updates this month.