September 2026: Prior auth support for radiology services starting Nov. 1

Meeting Senior Care Options (SCO) and One Care members where they are

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:

• Provider Portal: Your first resource for information
• Carelon: Prior authorization support for radiology services starting November 1 
  
• Upcoming Provider Portal authorization change effective November 1
  
• Register now: Upcoming Medicare Advantage webinars
• Provider webinar topic suggestion form
  
• New remittance message for Medicare Advantage members
• Claims guidance: Include NDC number 
• Provider Payment Guideline clarification: Preventive Service and Problem-Focused Visits
• Reminder: Annual Mental Health Wellness Exams
• Required model of care (MOC) training for SCO and One Care providers
• Prime update: Post‑Service Claim Edit (PSCE) program
  
• Mass General Brigham Health Plan Supplier Diversity Program (SDP)
• Mass General Brigham Health Plan’s drug fee schedules to be updated
• Find out how our Medicare Advantage team can support you and your patients
• 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

Provider Portal: Your first resource for information

To ensure the fastest and most efficient service, all providers and office staff are required to utilize the Provider Portal as the primary source for information before contacting Provider Services. The portal offers convenient, self-service access to a wide range of resources, including eligibility and benefits information, claims status, authorization details, and other important plan information.

When contacting Provider Services, representatives will ask whether the information has already been reviewed through the Provider Portal. If you are experiencing difficulty accessing or locating information, our representatives are happy to assist with troubleshooting and navigation. However, representatives will not verbally provide information that is readily available through the Provider Portal.

By using the Provider Portal as your first resource, you can often obtain the information you need more quickly while helping Provider Services focus on more complex inquiries that require direct assistance.

Thank you for partnering with us to create a more efficient provider experience.

Carelon: Prior authorization support for radiology services starting November 1 

Beginning November 1, 2026, Mass General Brigham Health Plan is introducing a new process to support prior authorizations for radiology services on commercial plans through Carelon Medical Benefits Management. Carelon partners with health plans across the country to enhance healthcare quality and provide administrative support for complex and advanced tests and treatments, ensuring care is appropriate, safe, and affordable.

Providers requesting elective radiology services starting November 1, 2026 will receive support from Carelon for pre-service and post-service reviews.

Through this new process, providers will be able to:

• Ensure patients have seamless access to radiology services
• More easily track the status of prior authorization requests for radiology services
• Mitigate claims denials through Carelon’s advanced platform and review process

For radiology services scheduled up to October 31, 2026, providers should continue to contact Mass General Brigham Health Plan for prior authorization. Prior authorizations and claims submitted to Mass General Brigham Health Plan before November 1, 2026 will be processed accordingly.

Starting November 1, 2026, providers can contact Carelon for authorizations of radiology services scheduled on or after November 1, 2026. If you are a Mass General Brigham-affiliated provider, you can also submit authorization for radiology services through the Epic system or the Carelon portal starting on November 1, 2026. Providers are strongly encouraged to obtain authorization before performing select outpatient radiology services.

The following radiology services are delegated to Carelon for prior authorization:

• Computed tomography (CT) imaging
• Computed tomography angiography (CTA)
• Magnetic resonance imaging (MRI)
• Magnetic resonance angiography (MRA)
• Magnetic resonance spectroscopy (MRS)
• Functional MRI (fMRI)
• Positron emission tomography (PET)
• Nuclear cardiology

Procedures conducted in an inpatient setting or on an emergent basis, such as those performed during an ER visit, or otherwise governed by federal or state laws are excluded from the program.

Members included in the radiology program

All Mass General Brigham Health Plan commercial members.

How to submit a request for prior authorization review

Starting November 1, 2026, providers can submit review requests or verify order numbers through the following methods:

Online
Access the Mass General Brigham Health Plan Provider Portal at Provider.MGBHP.org. From the Provider Portal, you can access the Carelon Provider Portal through single sign-on (SSO).

Phone
Call Carelon toll-free at 844-870-0609, Monday - Friday, 8 a.m. to 5 p.m. ET

Upcoming webinars

We want to make sure you have the information you need to support this new process. We will offer webinar and Q&A sessions for providers and office staff. These sessions will provide insights into the radiology prior authorization process, guidance on using the Carelon Provider Portal, and an opportunity to ask questions. Participation is highly recommended, even for those already familiar with Carelon.

The live webinars with Q&A will cover:

• The program and preauthorization request process
• Members and services requiring preauthorization
• Demonstration of the Carelon Provider Portal for entering order requests
• Access to additional resources
• Q&A with Carelon program leaders

Please register to attend at least one training session. After registration and participation in a webinar session, you will gain access to Carelon solution-specific training content. A recording of the training will be available to all registered users.

For more information

Online

• For resources to help your practice get started, go to Carelon MBM Radiology.
• Our Provider Connections webpage offers insights into the program and provides access to valuable resources, including order entry checklists and clinical guidelines.
• To learn more about Carelon MBM, please visit Carelon MBM.

Phone
Contact Mass General Brigham Health Plan Provider Services at 855-444-4647.

As always, thank you for your continued partnership and support as part of the Mass General Brigham Health Plan provider network to support the health of our members. We look forward to collaborating with you on this new process.

Upcoming Provider Portal authorization change effective November 1

Beginning November 1, 2026, Mass General Brigham Health Plan will update the provider authorization experience as part of our transition to Epic for utilization management.

Participating providers will continue to use the Provider Portal, but the authorization submission screen will have a different look and feel. All utilization management and authorization functionality will move to Tapestry Link, accessible via SSO from providers' existing Mass General Brigham Health Plan Provider Portal accounts.

Non-participating providers are not impacted by this change at this time and should continue to follow current authorization processes.

What is changing?

• Authorization submissions and related utilization management functionality for participating providers will be housed in Tapestry Link.
• Providers will continue to access authorization tools through the Provider Portal or eMPA.
• The authorization screen will look different, but current portal access and single sign-on are expected to support a seamless transition.
• Provider permissions will continue to align with site access currently managed through Mass General Brigham Health Plan systems.

What providers need to do

• Continue using the Provider Portal as you do today until the November 1, 2026, go-live date.
• Confirm that appropriate users at your organization have active portal access.

What is staying the same?

• Providers will continue to use the Provider Portal for access.
• Single sign-on will help providers access the updated authorization experience without a separate login.
• Non-participating provider processes remain unchanged.
• This change applies across lines of business.

Training and additional information

Mass General Brigham Health Plan will share training materials and additional information before November 1 to help providers prepare for the updated authorization experience. 

If you have questions, please contact Mass General Brigham Health Plan Provider Services at 855-444-4647.

Register now: Upcoming Medicare Advantage webinars

Partnering for Better Outcomes: Understanding Our Care Management Program

Please join the Mass General Brigham Health Plan Provider Engagement team for an educational webinar focused on our care management program and how it supports providers and members. Please note, this webinar is specific to Medicare Advantage.

Date: Wednesday, September 23
Time: 10-11 a.m. ET
Link: Register here

During this session, we will discuss:

• What care management means at Mass General Brigham Health Plan.
• The core principles of Mass General Brigham Health Plan Medicare Advantage Care Management.
  
• Care management programs available to members.
• How care management supports providers.

This webinar will provide valuable insights into the services available to your patients and highlight opportunities for collaboration between your practice and our Care Management team.

2027 Medicare Advantage Plans: Products, Updates, and What Providers Need to Know

The Mass General Brigham Health Plan Medicare Advantage Team invites you to a webinar reviewing our 2027 Medicare Advantage plan offerings. We will provide a detailed overview of each product, outline updates for the 2027 plan year, and share important information to support your patients and practice.

Please use the registration links below:

Date: Wednesday, October 7
Time: 10-11 a.m. ET
Link: Register here

or

Date: Wednesday, October 28
Time: 10-11 a.m. ET
Link: Register here

Be sure to watch out for additional webinars and educational sessions scheduled for November and December.

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.

New remittance message for Medicare Advantage members

In October, Mass General Brigham Health Plan will introduce a new remittance message for member’s enrolled in our Medicare Advantage plans. The informational message will appear on the Provider Remittance Advice as: Remit N549 – “Patient’s calendar year out-of-pocket maximum has been met.” This Remittance Advice Remark Code (RARC) will be displayed on claims to notify providers that the member has reached their calendar year out-of-pocket maximum and therefore has no applicable cost-sharing responsibility. N549 is considered an Alert RARC and is intended solely to provide information related to remittance processing; it is not associated with a specific claim adjustment or Claim Adjustment Reason Code (CARC). We encourage providers to review this new remark code to better understand claim payment details and member cost-share status.  

Claims guidance: Include NDC number 

As outlined in Mass General Brigham Health Plan’s Physician Administered Medications Provider Payment Guidelines, claims submitted using only HCPCS “J” codes for drugs will deny due to a missing NDC number. Providers should ensure that the appropriate NDC number is submitted along with the corresponding HCPCS code.

Provider Payment Guideline clarification: Preventive Service and Problem-Focused Visits

A clarification has been made to the Preventive Service and Problem-Focused Visit guidance in the Evaluation and Management Services Provider Payment Guideline when both services are reported on the same date of service. EvaluationandManagementServices.pdf

Updated language: The preventive service will be reimbursed at 100% of the contracted rate, and the problem-focused service will be reimbursed at 50% of the contracted rate.

Reminder: Annual Mental Health Wellness Exams

Per MA DOI Bulletin 2024-02, Mass General Brigham Health Plan covers an annual Mental Health Wellness Exam when billed under the medical benefit as follows:

Diagnosis Code: Z13.30, Encounter for screening examination for mental health and behavioral disorders, unspecified
Service Code: 90791, Psychiatric diagnostic evaluation
Modifier: 33, Preventive Services: When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.

Frequency limit: Annual
Services are provided at no member cost sharing except if the member is enrolled in an HSA qualified health plan (plan name includes the word ‘HSA’).

Mass General Brigham Health Plan’s Behavioral Health partner, Optum, will update our behavioral health providers via Provider Express.

For all Masshealth Members

Mass General Brigham Health Plan will follow the guidelines posted in Bulletin 408.

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 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 implement 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.

For additional information, view the PSCE frequently asked questions section on our Prime resource page. Support is available through the Prime Therapeutics Medical Pharmacy Solutions Provider Relations team at ProviderInquiry@PrimeTherapeutics.com.

Mass General Brigham Health Plan Supplier Diversity Program (SDP)

The Mass General Brigham Health Plan Supplier Diversity Program (SDP) has been created to promote equitable procurement practices by ensuring that diverse suppliers—including minority-owned, women-owned, veteran-owned, and other disadvantaged businesses—are actively considered and engaged in all sourcing activities.

This initiative supports the plan's commitment to diverse supplier selections with the objective of achieving and fostering greater supplier diversity.

The Massachusetts Executive Office of Health and Human Services (EOHHS) website dedicated to certifying/recertifying diverse suppliers can be found here: Certification Program for SDO | Mass.gov

EOHHS Diverse Certification Categories are defined as a business which is at least 51% owned, operated, and controlled daily by one or more (in combination) American citizens of the following ethnic minority and/or gender (e.g. woman-owned) and/or military veteran classifications:

• MBE - Minority Business Enterprise
• WBE - Woman Business Enterprise
• M/WBE - Minority and Woman Business Enterprise
• SDVOBE - Service-Disabled Veteran-Owned Business Enterprise
• VBE - Veteran-Owned Business Enterprise
• M/NPO - Minority Non-Profit Organization
• W/NPO - Women Non-Profit Organization
• M/W/NPO - Minority and Women Non-Profit Organization
• DOBE - Disability-Owned Business Enterprise
• LGBTBE - Lesbian, Gay, Bisexual, or Transgender Business Enterprise

Benefits of being certified as a Massachusetts Diverse Supplier through the EOHHS Supplier Diversity Office (SDO):

• Competitive advantages: Access to exclusive contracts, enhanced visibility in supplier databases, and specialized networking opportunities.
• Increased opportunities: The SDO’s goals include increasing diverse and small business spending through annual state agency spending benchmarks.
• Increased marketability: Diverse suppliers can enhance their marketability when bidding on public contracts. The SDO connects certified diverse businesses with business opportunities and resources that can help them grow and thrive.
• Support for underrepresented groups: Supplier diversity initiatives support underrepresented groups, such as Black, Latino, and LGBTQ+ individuals, who often face significant hurdles in accessing capital and contracting with the state.
• Economic prosperity: Supplier diversity drives financial returns, fosters innovation, enhances brand loyalty, and contributes to social and environmental impact.

Sign up today: Certification Program for SDO | Mass.gov

Mass General Brigham Health Plan’s drug fee schedules to be updated

Mass General Brigham Health Plan reviews its drug 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.

The next update will occur on October 1, 2026. Changes may involve both new and existing CPT and HCPCS codes and will include the planned quarterly update to physician administered drugs, immune globulin, vaccine, and toxoid fees.

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

Mass General Brigham Health Plan launched SCO (Senior Care Options) and One Care Dual 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

Thirteen (13) 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 code updates for September 2026. 

Medicare pharmacy updates

View updates here. 

Commercial pharmacy updates

View updates here. 

MassHealth pharmacy updates

View updates here.