Provider payment guidelines

Reimbursement for out-of-network urgent care centers

Beginning on July 3, 2024, and ending on October 1, 2024, Mass General Brigham Health Plan will reimburse out-of-network urgent care centers in Massachusetts as requested below. This is in support of the recent directive from the Massachusetts Executive Office of Health and Human Services (EOHHS) and bulletin from MassHealth. Mass General Brigham Health Plan will reimburse urgent care centers in eastern Massachusetts* as follows:

• For Commercial members receiving services provided in urgent care centers with providers with whom Mass General Brigham Health Plan has a contract, but who do not participate in a member’s health plan, Mass General Brigham Health Plan will provide reimbursement for medically necessary urgent care services at the contracted rate for delivered services. Out-of-network providers are not allowed to balance bill members during this time.
  
  
• For Commercial members receiving services provided in urgent care centers with providers with whom Mass General Brigham Health Plan does not have any contract, Mass General Brigham Health Plan will reimburse medically necessary urgent care services at a rate equal to 135% percent of the rate paid by Medicare for medically necessary urgent care services. Out-of-network providers are not allowed to balance bill members during this time. 
  
  
• The MassHealth Program will reimburse at 100 percent of Medicaid.

Non-contracted providers in Massachusetts should submit claims directly to Mass General Brigham Health Plan (Payer ID: 04293). Please review our payment options and claims resource page before submitting claims using one of the following methods:

• Call Provider Service at 855-444-4647
• Mail paper claims to PO Box #323, Glen Burnie, MD 21060
• Submit a claim through the Provider Portal at MassGeneralBrighamHealthPlan.org

For questions about reimbursement, please email HealthPlanProvRelations@mgb.org or visit the Provider Portal at Provider.MassGeneralBrighamHealthPlan.org.

*Commercial is limited to these counties: Essex, Middlesex, Suffolk, Norfolk, Bristol, Plymouth, Barnstable, Dukes, and Nantucket

Response to ED Boarding Crisis 

Mass General Brigham Health Plan complies with regulatory guidance to ensure Hospitals are reimbursed for behavioral health crisis evaluations and stabilization services provided in the Emergency Department in response to the ED Boarding crisis.

This applies to:

• Commercial members, for dates of service 11/01/2022 and forward per MA DOI Bulletin 2022-08.
   
• Medicaid members, for dates of service 01/03/2023 through 09/30/2023, per Mass Health guidance including MCE Bulletin 93 published November 2022.
• Medicaid members, for dates of service 10/01/2023 and forward, per the MA Inpatient Acute General RFA effective 10/01/2023.

Mass General Brigham Health Plan complies with regulatory guidance to ensure Hospitals are reimbursed for behavioral health crisis evaluations and stabilization services, crisis management, recovery support navigators and the initiation of medication treatment for Opioid Use Disorders in the ED per the MA Inpatient Acute General RFA effective 10/01/2023.