November 2025: Upcoming provider events and webinars

Last chance: Join us for the Fall Regional Provider Meeting on November 10

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:

• Prime Therapeutics: Specialty drug management update and upcoming webinars
• Provider FAQ and webinar: Dual Eligible Special Needs Plans (D-SNPs)
• Webinar: Medicare Advantage updates
• Reminder about our coverage of GLP-1 medications
• Update to Provider Enrollment email requests effective November 1
• Explanation of Payment (EOP) updates effective October 1
• 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
• MassHealth EVV training for personal care and home health providers
• Meet the Provider Relations team: Brandon Veazie
• 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

Prime Therapeutics: FAQs and upcoming webinars

You recently received information regarding Mass General Brigham Health Plan contracting with the Medical Pharmacy Solutions team at Prime Therapeutics Management (Prime) to manage a new process for reviewing and approving certain specialty drugs effective January 1, 2026. To view a list of FAQs, please visit the Prime Therapeutics resource page. 

To help providers better prepare for this new program, we are offering online training. The Prime team of experts will walk you through the prior approval process. Understanding our new procedures will help ensure that your authorizations are processed promptly and accurately.

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. 

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:

Webinar: Medicare Advantage updates

You're invited to a webinar on December 8 from 10-11 a.m. to review the Mass General Brigham Health Plan Medicare Advantage product updates effective January 1, 2026.

Agenda:

• 2026 Medicare updates
• Medicare open enrollment timeline
• Mass General Brigham Health Plan Medicare Advantage product updates
• Case management review

Register now

Reminder about our coverage of GLP-1 medications 

Beginning January 1, 2026, we are updating our coverage of GLP-1 medications for fully insured commercial members. While we are continuing to cover GLP-1s for type 2 diabetes, we will no longer provide coverage of GLP-1 medications for weight management. This coverage change is effective on January 1, 2026, for individual and small groups and upon renewal in 2026 for large groups.

Coverage for GLP-1s approved to treat type 2 diabetes is not changing. This includes Ozempic, Mounjaro, Trulicity, and others. Please note that these medications will continue to require prior authorization. 

In addition, employer accounts with 50 or more enrolled subscribers will have the option to add coverage of GLP-1s for weight management when their plans renew in 2026.  

We recognize the significant impact of GLP-1 medications, and we are committed to supporting our members on their healthcare journeys. Members have opportunities to connect with our dedicated team of service professionals for additional information and support. Our teams will review available options and programs to help members manage their weight loss journeys. Care management is also available to all our members at no additional cost. 

For more information about this change, please visit our GLP-1 coverage page. If you have questions, please contact our Provider Services team at 855-444-4647 (Monday through Friday, 8 a.m. to 5 p.m.; closed from 12-12:45 p.m.). 

Thank you for your support and all that you do to provide high-quality care for our members. 

Update to Provider Enrollment email requests effective November 1

As previously announced, effective November 1, 2025, 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

Explanation of Payment (EOP) updates effective October 1

Please review the following Explanation of Payment (EOP) updates going into effect on October 1:

MGBHP Payment Date and EOP Payment Date fields

New fields, MGBHP Payment Date and EOP Payment Date, have been added to the Explanation of Payment (EOP) to help identify the two dates. Example below:

Requesting an administrative appeal

Requests for claims review/appeal requests must be submitted in writing, within 90 days of the Explanation of Payment (EOP) along with any relevant information and documentation to support the request. Requests received beyond the 90-day appeal window (or, for Level II requests, beyond the 60-day appeal window from the Level I decision) cannot be considered. When submitting a provider appeal, please use the Request for Claim Review Form (available on MGBHP.org) and submit your request via the Provider Portal (Provider.MGBHP.org). Additional information on appeal submission requirements is available via the Provider Manual at MGBHP.org. As a reminder, request for reviews should be submitted within 90 days of the EOP Payment Date as opposed to the MGBHP Payment Date.

Non-contracted Medicare providers

If a claim is partially or fully denied for payment, a non-contracted provider must request reconsideration of the denial within 65 calendar days from the remittance notification date. When submitting the reconsideration of the denial of payment of a signed Waiver of Liability form must be included. You can locate this form at: https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Notices-and-Forms.

The purpose of this Waiver of Liability form is to hold the enrollee harmless regardless of the outcome of the appeal. With the appeal, the non-contracted provider should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the providers request for reimbursement. Please submit your appeal in writing to:

Mass General Brigham Health Plan
Appeals & Grievances
399 Revolution Drive
Suite 850
Somerville, MA 02145

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, annual, 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.

MassHealth EVV training for personal care and home health providers

Check out the below upcoming live webinar training opportunities to support you in using your chosen Electronic Visit Verification (EVV) system and monitor your compliance. Please note that thresholds of compliance will continue to be set and announced through the managed care entities and each MA program (e.g., Home Health, Group Adult Foster Care, etc.) that you contract with.  

Recordings of these sessions will be available after the sessions if you cannot attend the live calls. Self-paced online courses will continue to be available 24/7 in Sandata Learn, including the Aggregator training if you have chosen an Alternate EVV Vendor.  

Session 1: Getting Caught Up with EVV in Massachusetts 
Date: Monday, November 10, 2025 
Time: 10-11 a.m. ET 
REGISTER HERE 

This session will review EVV basics and helpful reminders for providers who have not yet started or are just starting to onboard with EVV in Massachusetts. This session is applicable to providers who have chosen either an Alternate EVV Vendor or Sandata EVV.   

Session 2: Boost Your EVV Compliance in Massachusetts 
Date: Wednesday, November 19, 2025 
Time: 2-3 p.m. ET 
REGISTER HERE 

This session will cover tips and tricks for boosting EVV Compliance in Massachusetts. This session will be most helpful for providers who have already started capturing EVV. This session is applicable to providers who have chosen either an Alternate EVV Vendor or Sandata EVV. 

Note: The live learning sessions will be recorded; parts of which may be used as an EVV training resource. 

Contacts and Resources  

View the Massachusetts Detailed Instructions for Onboarding for a step-by-step guide on how to get started with MA EVV.  
For technical help in using the EVV system, please Submit a Request via Sandata On-Demand.  You may also call the Customer Support line at 833-511-0164. 
For general questions about the Massachusetts EVV program, please email EVVfeedback@Mass.gov.  You can also visit the MA-EOHHS EVV website for more  

Meet the Provider Relations team: Brandon Veazie

Brandon Veazie has been a valued member of our Provider Relations team for three years, supporting providers within Boston Medical Center, Cambridge Hospital, Lawrence Hospital, the Community Health Center network, and the CHA network. Brandon’s extensive knowledge of our Customer Service Center, Provider Portal, and overall provider network makes him an exceptional resource for both our provider partners and internal teams.

If you're in Brandon's network area and would like to get in touch with him, please email bveazie@mgb.org.

Help us improve the member experience — confirm your next available appointments

Please take a few minutes to complete this brief form. Completing this form 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 both 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 who 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 who may not benefit from the Medicare Prescription Payment Plan.

• Low yearly out-of-pocket covered Part D drug costs (<$2,100 per year).
• Members receiving or eligible for Extra Help from Medicare.
• Members receiving or eligible for a Medicare Savings Program.
• Members receiving help paying for drugs from other organizations, like a State Pharmaceutical Assistance Program (SPAP), a coupon program, or other health coverage.
• Members 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

Forty-five (45) 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 the October 2025 new code summary here.

View code updates for November 2025 here.

2026 Medicare pharmacy updates

View updates for 2026 here. 

Formulary updates

View the formulary updates here.