Interstitial Cystitis Awareness Month: Raising awareness, understanding symptoms, and exploring treatment options
September marks Interstitial Cystitis (IC) Awareness Month, a time to shine a spotlight on a chronic condition that affects millions but often goes unnoticed. For the 4-12 million people potentially living with IC, the struggle is real—yet many may feel their pain and discomfort are dismissed due to its invisibility and the complexity of diagnosis. Now is the perfect time to learn about the symptoms, causes, and available treatments for this condition, and to help those who live with IC feel seen and understood. Read the full article.
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MGBHP Provider Service Team can assist our provider network with inquiries and requests including the following:
• General provider tools and resources and/or MGBHP policies and procedures questions
• Member benefits & coverage
• Claim review/appeals requests
• PCP referrals and/or prior authorization requirements
• Medical drug specialties coverage requirements
• Copies of relevant provider materials
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
• EOP
• And more
Register and access the portal here: Provider.MGBHP.org
In this issue:
- An update on our coverage of GLP-1 medications
- Prime Therapeutics: Specialty drug management update and upcoming webinars
- Action required: Attest to your provider directory information in the Provider Portal (now live)
- Explanation of Payment (EOP) updates effective October 1
- September webinar: Durable medical equipment (DME)
- Utilization of language services report
- New claims process for Part D vaccines when administered in a provider's office
- Meet the Provider Relations team: Sue Medeiros
- Utilization Management updates – Effective September 1
- Video: Submitting claims and claims reviews in the Provider Portal
- Select a designated Provider Portal User Administrator
- Medicare Advantage HHA provider communication
- Help us keep directory information up to date
- Medical policy updates
- Drug code and code updates
- Formulary updates
An update on our coverage of GLP-1 medications
We are writing to remind you about a change to our coverage of GLP-1 medications.
Beginning on 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.
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.
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 weight loss. Care management is also available to all our members at no additional cost.
Mass General Brigham Health Plan is pleased to offer comprehensive benefits to help members achieve their health and wellness goals. Our programs include:
- Healthier You: A year-long program for members who are looking to lose weight, become more active, and reduce the risk of chronic conditions, such as diabetes and heart disease.
- Access to health coaches: One-on-one health coaching by phone at no cost to help members make a wellness plan and connect to resources in the community.
- Fitness and weight loss reimbursements: For subscriptions, programs, or activities at qualifying fitness facilities and up to six months of membership fees at a qualified weight-loss program.
- Mental health support: Comprehensive virtual and in-person mental health services.
- Care Management Programs: A variety of programs to support our members’ health needs.
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.
For more information about this change, please visit the GLP-1s coverage page on our website. 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.
Prime Therapeutics: Specialty drug management update and upcoming webinars
Mass General Brigham Health Plan is committed to providing our members with access to high-quality health care that is consistent with evidence-based, nationally recognized clinical criteria and guidelines. Therefore, we will be implementing a change in the way we manage certain specialty drugs that fall under the medical benefit. This new program will be administered by the Medical Pharmacy Solutions team at Prime Therapeutics (Prime).
Beginning December 22, 2025, providers should begin contacting Prime to obtain prior authorizations via web, fax, or phone or the in-scope drugs for our members with dates of service on or after January 1, 2026. Please note the drugs considered in-scope vary by member plan.
The Medical Pharmacy Solutions team at Prime will host web-based training sessions in November and December 2025. Please watch your email for the October and November newsletters and our Prime resource page for FAQs, updates, and additional information about our training sessions.
We appreciate your support to ensure that our members continue receiving high-quality and clinically appropriate care. If you have questions, please contact the Mass General Brigham Health Plan provider service line at 855-444-4647 or HealthPlanproviderservice@mgb.org.
Action required: Attest to your provider directory information in the Provider Portal (Now Live)
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.
If you have any questions, please contact Provider Relations at HealthPlanProvRelations@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 field
A new field, MGBHP Payment Date, has been added to the Explanation of Payment (EOP) to identify MGBHP pay date. 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
September webinar: Durable medical equipment (DME)
Please join us on September 24 for a webinar geared towards providing our durable medical equipment (DME) network with an overview of tools and resources available to them. In addition, we will provide an overview of how to submit DME requests via the Provider Portal. Please note, this webinar is for medical providers only.
Date: September 24, 2025
Time: 12 - 1 p.m.
Registration: Click here
Utilization of language services report
Mass General Brigham Health Plan has created a report that depicts language services completed at each affiliated medical facility. Based on the language services data, the majority of language services completed were for the following languages:
For additional information, please view the full report.
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: Sue Medeiros
Sue Medeiros has been a valued member of our Provider Relations team for the past two years. She supports Children’s Hospital and also works closely with providers in our Southeastern network, including Brockton, Baystate, Cape Cod, Sturdy, Southcoast, Revere, and Rhode Island.
If you're in Sue's network area and would like to get in touch with her, please email: smedeiros15@mgb.org
Utilization Management updates – Effective September 1
For the home care changes effective September 1, 2025, we would like to clarify that these updates do not impact commercial lines of business.
Home Care authorization submission updates
- Mass General ACO members only:
Skilled Nursing and Medication Administration Visits (MAVs) must be submitted under a single authorization. - All other lines of business:
Skilled Nursing visits must continue to be submitted on a separate authorization. - All lines of business:
Home Physical Therapy and Home Occupational Therapy requests must be submitted on separate authorizations.
Video: Submitting claims and claims reviews in the Provider Portal
We’re excited to announce you can submit claims and claims reviews in the Provider Portal. When submitting a claim or claim review, a transaction number confirming receipt of submission will be available and providers can track the status of a submission within the Provider Portal. Please note, a claim review form must be completed and attached to the online claim review submission. Please review the video walkthrough of the new features below or read the overview. If you need assistance with the Provider Portal, please contact HealthPlanprweb@mgb.org.
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.
Medicare Advantage HHA provider communication
For Medicare Advantage product line, Mass General Brigham Health Plan adopted the billing guidelines found in Medicare Claims Processing Manual for Home Health. Please reference:
Sections:
40.1 for the submission of the NOA (notification of admission)
40.2 for the Rev code, type of bill, HIPPS Code and billing increments
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
Eleven (11) medical policies were reviewed and passed by Mass General Brigham Health Plan’s Medical Policy Committee. View a summary of the updates here. 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 September 2025 here.
Formulary updates
View the formulary updates here.