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Provider resources | Mass General Brigham Health Plan
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class="frm_item"> <input type="text" class="hs-search-field__input" name="term" autocomplete="off" aria-label="Search" placeholder="Search"> </div> <input type="hidden" name="type" value="SITE_PAGE"> <input type="hidden" name="type" value="BLOG_POST"> <input type="hidden" name="type" value="LISTING_PAGE"> <div class="frm_btn"> <button aria-label="Search"></button> </div> </form> </div> <ul class="hs-search-field__suggestions"></ul> </div></div> </div> </div> </div> </header> </div></div> <main id="main-content" class="body-container-wrapper home-page"> <div class="container-fluid home-row1"> <div class="row-fluid-wrapper"> <div class="row-fluid"> <div class="span12 widget-span widget-type-cell " style="" data-widget-type="cell" data-x="0" data-w="12"> <div class="row-fluid-wrapper row-depth-1 row-number-1 dnd-section"> <div class="row-fluid "> <div class="span12 widget-span widget-type-cell dnd-column" style="" data-widget-type="cell" data-x="0" data-w="12"> <div class="row-fluid-wrapper row-depth-1 row-number-2 dnd-row"> <div class="row-fluid "> <div class="span12 widget-span widget-type-custom_widget dnd-module" style="" data-widget-type="custom_widget" data-x="0" data-w="12"> <div id="hs_cos_wrapper_widget_1669138550167" class="hs_cos_wrapper hs_cos_wrapper_widget hs_cos_wrapper_type_module" style="" data-hs-cos-general-type="widget" data-hs-cos-type="module"><div class="banner-wrapper" id=""> <section class="hero-landing"> <div class="hero__bg hero-bg-7" style="background-image:url(https://massgeneralbrighamhealthplan.org/hubfs/iStock-1201730019.jpg); background-position:center center;"></div> <div class="hero__inner"> <h1 class="hero__title"> Top tools for your practice </h1> <div class="hero__content"> <div> <p>Welcome to the Provider resource center. We’ve made it easy for you to do business with Mass General Brigham Health Plan by organizing popular forms and resources on one page.</p> </div> </div> </div> </section> </div> </div> </div><!--end widget-span --> </div><!--end row--> </div><!--end row-wrapper --> </div><!--end widget-span --> </div><!--end row--> </div><!--end row-wrapper --> </div><!--end widget-span --> </div> </div> </div> <div class="container-fluid home-row2"> <div class="row-fluid-wrapper"> <div class="row-fluid"> <div class="span12 widget-span widget-type-cell " style="" data-widget-type="cell" data-x="0" data-w="12"> <div class="row-fluid-wrapper row-depth-1 row-number-1 dnd-section"> <div class="row-fluid "> <div class="span12 widget-span widget-type-cell dnd-column" style="" data-widget-type="cell" data-x="0" data-w="12"> <div class="row-fluid-wrapper row-depth-1 row-number-2 dnd-row"> <div class="row-fluid "> <div class="span6 widget-span widget-type-custom_widget dnd-module" style="" data-widget-type="custom_widget" data-x="0" data-w="6"> <div id="hs_cos_wrapper_module_1686000450399" class="hs_cos_wrapper hs_cos_wrapper_widget hs_cos_wrapper_type_module widget-type-rich_text" style="" data-hs-cos-general-type="widget" data-hs-cos-type="module"><span id="hs_cos_wrapper_module_1686000450399_" class="hs_cos_wrapper hs_cos_wrapper_widget hs_cos_wrapper_type_rich_text" style="" data-hs-cos-general-type="widget" data-hs-cos-type="rich_text"><div> <h2>Manuals</h2> <ul> <li><a href="https://resources.massgeneralbrighamhealthplan.org/providers/Commercial%20Provider%20Manual.pdf" rel="noopener" target="_blank">Commercial Provider manual</a></li> <li><a href="https://resources.massgeneralbrighamhealthplan.org/providers/MGB%20ACO%20Provider%20Manual.pdf" rel="noopener" target="_blank">Mass General Brigham ACO Provider manual</a></li> <li><a href="https://resources.massgeneralbrighamhealthplan.org/providers/Medicare%20Advantage%20Provider%20Manual.pdf" target="_blank" rel="noopener noreferrer">Medicare Advantage Provider manual</a></li> </ul> </div></span></div> </div><!--end widget-span --> <div class="span6 widget-span widget-type-custom_widget dnd-module" style="" data-widget-type="custom_widget" data-x="6" data-w="6"> <div id="hs_cos_wrapper_module_1686000477909" class="hs_cos_wrapper hs_cos_wrapper_widget hs_cos_wrapper_type_module widget-type-rich_text" style="" data-hs-cos-general-type="widget" data-hs-cos-type="module"><span id="hs_cos_wrapper_module_1686000477909_" class="hs_cos_wrapper hs_cos_wrapper_widget hs_cos_wrapper_type_rich_text" style="" data-hs-cos-general-type="widget" data-hs-cos-type="rich_text"><div><span style="font-family: 'Roboto Slab'; font-size: 2.625rem; background-color: transparent;">Education</span></div> <ul> <li><a href="/providers/education" rel="noopener">Provider education center</a></li> <li><a href="/providers/bh-resources" rel="noopener">Primary care provider (PCP) behavioral health resources</a></li> <li><a href="/providers/product-reference" rel="noopener">Product reference information</a></li> <li><a href="/providers/payment-options" rel="noopener">Electronic payment options</a></li> <li><a href="https://5977230.fs1.hubspotusercontent-na1.net/hubfs/5977230/Provider%20Portal%20Training%20Overview%202024.pdf" rel="noopener" target="_blank">Provider portal training overview</a></li> </ul></span></div> </div><!--end widget-span --> </div><!--end row--> </div><!--end row-wrapper --> </div><!--end widget-span --> </div><!--end row--> </div><!--end row-wrapper --> </div><!--end widget-span --> </div> </div> </div> <div class="container-fluid home-row3"> <div class="row-fluid-wrapper"> <div class="row-fluid"> <div class="span12 widget-span widget-type-cell " style="" data-widget-type="cell" data-x="0" data-w="12"> <div class="row-fluid-wrapper row-depth-1 row-number-1 dnd-section"> <div class="row-fluid "> <div class="span12 widget-span widget-type-cell dnd-column" style="" data-widget-type="cell" data-x="0" data-w="12"> <div class="row-fluid-wrapper row-depth-1 row-number-2 dnd-row"> <div class="row-fluid "> <div class="span12 widget-span widget-type-custom_widget dnd-module" style="" data-widget-type="custom_widget" data-x="0" data-w="12"> <div id="hs_cos_wrapper_widget_1686000436452" class="hs_cos_wrapper hs_cos_wrapper_widget hs_cos_wrapper_type_module widget-type-header" style="" data-hs-cos-general-type="widget" data-hs-cos-type="module"> <span id="hs_cos_wrapper_widget_1686000436452_" class="hs_cos_wrapper hs_cos_wrapper_widget hs_cos_wrapper_type_header" style="" data-hs-cos-general-type="widget" data-hs-cos-type="header"><h2>Forms</h2></span></div> </div><!--end widget-span --> </div><!--end row--> </div><!--end row-wrapper --> <div class="row-fluid-wrapper row-depth-1 row-number-3 dnd-row"> <div class="row-fluid "> <div class="span12 widget-span widget-type-custom_widget dnd-module" style="" data-widget-type="custom_widget" data-x="0" data-w="12"> <div id="hs_cos_wrapper_widget_1669138581076" class="hs_cos_wrapper hs_cos_wrapper_widget hs_cos_wrapper_type_module" style="" data-hs-cos-general-type="widget" data-hs-cos-type="module"><div class="accordion widget_1669138581076" id=""> <ul> <li class="accordion-item"> <a class="accordion-item__title" href="javascript:void(0)"> Prior authorization forms </a> <div class="accordion-content"> <div class="accordion-item__body"> <p><a href="https://resources.massgeneralbrighamhealthplan.org/utilizationmgmt/PA_CardiacImaging.pdf" rel="noopener noreferrer" target="_blank">Cardiac Imaging Prior Authorization Form</a><br><a href="https://resources.massgeneralbrighamhealthplan.org/utilizationmgmt/PA_CT_CTA_MRI_MRA.pdf" rel="noopener noreferrer" target="_blank">CT/CTA/MRI/MRA Prior Authorization Form</a><br><a href="https://resources.massgeneralbrighamhealthplan.org/providers/FRM_NonEmergencyTransportation_final.pdf" rel="noopener noreferrer" target="_blank">Non-Emergency Medically Necessary Ground Transportation Form</a><br><a href="https://resources.massgeneralbrighamhealthplan.org/utilizationmgmt/PA_PETCT.pdf" rel="noopener noreferrer" target="_blank">PET — PET CT Prior Authorization Form</a><br><a href="https://resources.massgeneralbrighamhealthplan.org/utilizationmgmt/PARequestForm.pdf" rel="noopener noreferrer" target="_blank">Prior Authorization Request Form</a><br><a href="https://resources.massgeneralbrighamhealthplan.org/utilizationmgmt/Assessment_PsychNeuro.pdf" rel="noopener noreferrer" target="_blank">Psychological and Neuropsychological Assessment Supplemental Form</a></p> </div> </div> </li> <li class="accordion-item"> <a class="accordion-item__title" href="javascript:void(0)"> Pharmacy forms </a> <div class="accordion-content"> <div class="accordion-item__body"> <p><a href="https://resources.massgeneralbrighamhealthplan.org/pharmacy/Forms/StdRxPAForm_SPCandNSPC.pdf" rel="noopener noreferrer" target="_blank">Prior authorization form — Specialty and Non-Specialty (PDF)</a><br><a href="https://resources.massgeneralbrighamhealthplan.org/pharmacy/Forms/StdRxPAForm_HepC.pdf" rel="noopener noreferrer" target="_blank">Hepatitis C Medications Prior Authorization Form (PDF)</a><br><a href="https://resources.massgeneralbrighamhealthplan.org/pharmacy/Forms/StdRxPAForm_SYNAGIS.pdf" rel="noopener noreferrer" target="_blank">Synagis Prior Authorization Form (PDF)</a></p> </div> </div> </li> <li class="accordion-item"> <a class="accordion-item__title" href="javascript:void(0)"> Enrollment and credentialing forms </a> <div class="accordion-content"> <div class="accordion-item__body"> <p><a href="https://resources.massgeneralbrighamhealthplan.org/providers/HCAS%20FORM%202023.pdf" rel="noopener" target="_blank">HCAS provider information form</a><br><span>Update your directory information.</span></p> <p><a href="https://resources.massgeneralbrighamhealthplan.org/provider/Forms/Standardized_Provider_Info_Form.pdf" rel="noopener">Provider info change form</a><br><span>Enroll or remove providers from your practice. If you're registered for </span><a href="https://provider.massgeneralbrighamhealthplan.org" rel="noopener noreferrer" target="_blank">our Provider portal</a><span>, you can use our convenient online enrollment tool instead. </span><br><span> </span><br><a href="https://www.irs.gov/pub/irs-pdf/fw9.pdf">W9</a><br><span>Provide your tax identification number (TIN) to Mass General Brigham Health Plan. </span></p> </div> </div> </li> <li class="accordion-item"> <a class="accordion-item__title" href="javascript:void(0)"> Other provider forms </a> <div class="accordion-content"> <div class="accordion-item__body"> <p><a href="https://www.mass.gov/doc/notification-of-birth-form-nob-1-2/download?_ga=2.125717709.650685260.1674066632-799648456.1666898138" rel="noopener noreferrer" target="_blank">MassHealth Notification of Birth Form (NOB-1)</a><br><a href="https://resources.massgeneralbrighamhealthplan.org/provider/forms/Provider_Audit_Appeal.pdf" rel="noopener noreferrer" target="_blank">Provider Audit Appeal Form</a><br><a href="https://www.hcasma.org/attach/Interactive-appeal-form-final-aug-2013.pdf" rel="noopener noreferrer" target="_blank">Request for Claim Review Form</a><br><a href="https://resources.massgeneralbrighamhealthplan.org/provider/forms/Unlisted_Special_Report_Form.pdf" rel="noopener noreferrer" target="_blank">Unlisted/NOC/NOS/NES Special Report Form</a><br><a href="https://resources.massgeneralbrighamhealthplan.org/members/masshealth/Mass_General_Brigham_Health_Plan_Designation_of_Appeal_Rep_Form.pdf" rel="noopener" target="_blank">Mass General Brigham ACO <span>Appeal and Grievance Designation of Authorized Representative Form</span></a></p> </div> </div> </li> </ul> </div> </div> </div><!--end widget-span --> </div><!--end row--> </div><!--end row-wrapper --> </div><!--end widget-span --> </div><!--end row--> </div><!--end row-wrapper --> </div><!--end widget-span --> </div> </div> </div> <div class="container-fluid home-row4"> <div class="row-fluid-wrapper"> <div class="row-fluid"> <div class="span12 widget-span widget-type-cell " style="" data-widget-type="cell" data-x="0" data-w="12"> <div class="row-fluid-wrapper row-depth-1 row-number-1 row4-row-0-padding dnd-section"> <div class="row-fluid "> <div class="span12 widget-span widget-type-cell dnd-column" style="" data-widget-type="cell" data-x="0" data-w="12"> <div class="row-fluid-wrapper row-depth-1 row-number-2 dnd-row"> <div class="row-fluid "> <div class="span12 widget-span widget-type-custom_widget dnd-module" style="" data-widget-type="custom_widget" data-x="0" data-w="12"> <div id="hs_cos_wrapper_widget_1669138645067" class="hs_cos_wrapper hs_cos_wrapper_widget hs_cos_wrapper_type_module widget-type-header" style="" data-hs-cos-general-type="widget" data-hs-cos-type="module"> <span id="hs_cos_wrapper_widget_1669138645067_" class="hs_cos_wrapper hs_cos_wrapper_widget hs_cos_wrapper_type_header" style="" data-hs-cos-general-type="widget" data-hs-cos-type="header"><h2>Other resources</h2></span></div> </div><!--end widget-span --> </div><!--end row--> </div><!--end row-wrapper --> </div><!--end widget-span --> </div><!--end row--> </div><!--end row-wrapper --> </div><!--end widget-span --> </div> </div> </div> <div class="container-fluid home-row5"> <div class="row-fluid-wrapper"> <div class="row-fluid"> <div class="span12 widget-span widget-type-cell " style="" data-widget-type="cell" data-x="0" data-w="12"> <div class="row-fluid-wrapper row-depth-1 row-number-1 dnd-section row5-row-0-padding"> <div class="row-fluid "> <div class="span12 widget-span widget-type-cell dnd-column" style="" data-widget-type="cell" data-x="0" data-w="12"> <div class="row-fluid-wrapper row-depth-1 row-number-2 dnd-row"> <div class="row-fluid "> <div class="span12 widget-span widget-type-custom_widget dnd-module" style="" data-widget-type="custom_widget" data-x="0" data-w="12"> <div id="hs_cos_wrapper_widget_1669138659834" class="hs_cos_wrapper hs_cos_wrapper_widget hs_cos_wrapper_type_module" style="" data-hs-cos-general-type="widget" data-hs-cos-type="module"><div class="accordion widget_1669138659834" id=""> <ul> <li class="accordion-item"> <a class="accordion-item__title" href="javascript:void(0)"> Practice guidelines </a> <div class="accordion-content"> <div class="accordion-item__body"> <p>Mass General Brigham Health Plan adopts, endorses and implements these evidence-based guidelines from national sources, professional organizations, or developed by regional collaborative groups. Guidelines serve as a means of establishing standards among medical and behavioral health providers to improve health outcomes. They are not intended to replace clinical judgment.<br><br><strong>ADHD</strong><br><a href="https://publications.aap.org/pediatrics/article/144/4/e20192528/81590/Clinical-Practice-Guideline-for-the-Diagnosis" rel="noopener" target="_blank">Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents</a></p> <p><strong>Anxiety </strong><br><a href="https://www.jaacap.org/action/showPdf?pii=S0890-8567%2820%2930280-X" rel="noopener" target="_blank">Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders</a></p> <p><strong>Asthma</strong><br><a href="https://ginasthma.org/2023-gina-main-report/" rel="noopener" target="_blank">Asthma Management and Prevention</a><br><a href="https://www.nhlbi.nih.gov/resources/2020-focused-updates-asthma-management-guidelines" rel="noopener" target="_blank">Asthma Management Guidelines</a></p> <p><strong>COPD/Emphysema</strong><br><a href="https://goldcopd.org/clinicians/" rel="noopener" target="_blank">COPD Management Guidelines</a></p> <p><strong>Depression</strong><br><a href="https://www.healthquality.va.gov/guidelines/MH/mdd/" rel="noopener" target="_blank">Adult Guidelines - Major Depressive Disorder</a><br><a href="https://www.jaacap.org/action/showPdf?pii=S0890-8567%2822%2901852-4" rel="noopener" target="_blank">Children and Adolescent Guidelines - Major Depressive Disorders</a></p> <p><strong>Diabetes</strong><br><a href="https://diabetesjournals.org/care/issue/46/Supplement_1" rel="noopener noreferrer" target="_blank">American Diabetes Association Guidelines</a></p> <p><strong>Heart Failure</strong><br><a href="https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063" rel="noopener" target="_blank">Management of Heart Failure</a></p> <p><strong>High Blood Pressure</strong><br><a href="https://jamanetwork.com/journals/jama/fullarticle/1791497" rel="noopener" target="_blank">Guideline for the Management of High Blood Pressure in Adults</a><br><a href="https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065" rel="noopener" target="_blank">Management of High Blood Pressure</a></p> <p><strong>HIV/AIDS</strong><br><a href="https://clinicalinfo.hiv.gov/en/guidelines" rel="noopener noreferrer" target="_blank">HIV/AIDS Treatment Information Service Guidelines</a></p> <p><strong>Osteoporosis</strong><br><a href="https://pro.aace.com/clinical-guidance/2020-clinical-practice-guidelines-diagnosis-and-treatment-postmenopausal" rel="noopener" target="_blank">Guidelines for Postmenopausal Osteoporosis</a></p> <p><strong>Perinatal care guidelines</strong><br><a href="https://5977230.fs1.hubspotusercontent-na1.net/hubfs/5977230/MHQP%20Perinatal%20Care%20Guidelines%202024.pdf" target="_blank" rel="noopener noreferrer">Perinatal Care Guidelines - Massachusetts Health Quality Partners</a></p> <p><strong>Preventive care guidelines</strong><br><a href="https://5977230.fs1.hubspotusercontent-na1.net/hubfs/5977230/MHQP%20Adult%20Preventative%20Care%20Guidelines%202024.pdf" target="_blank" rel="noopener noreferrer">Adult Preventive Care Guidelines - Massachusetts Health Quality Partners</a><br><a href="https://5977230.fs1.hubspotusercontent-na1.net/hubfs/5977230/MHQP%20Pediatric%20Preventative%20Care%20Guidelines%202024.pdf" target="_blank" rel="noopener noreferrer">Pediatric Preventive Care Guidelines - Massachusetts Health Quality Partners</a><br><a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations" rel="noopener" target="_blank">US Preventive Task Force (USPTF) Recommendations</a></p> <p><strong>Substance Use Disorder/Alcohol Use Disorder</strong><br><a href="https://sitefinitystorage.blob.core.windows.net/sitefinity-production-blobs/docs/default-source/guidelines/npg-jam-supplement.pdf?sfvrsn=a00a52c2_2" rel="noopener" target="_blank">Guidelines for the Treatment of Opioid Use Disorder</a><br><a href="https://www.asam.org/docs/default-source/quality-science/the_asam_clinical_practice_guideline_on_alcohol-1.pdf?sfvrsn=ba255c2_2" rel="noopener" target="_blank">Guidelines on Alcohol Withdrawal Management</a></p> <p><strong>Optum Resources for Mental Health/Behavioral Health</strong><br><a href="https://www.providerexpress.com/content/ope-provexpr/us/en/clinical-resources/guidelines-policies/cpg.html" rel="noopener" target="_blank">Clinical Practice Guidelines</a></p> </div> </div> </li> <li class="accordion-item"> <a class="accordion-item__title" href="javascript:void(0)"> Drug alerts </a> <div class="accordion-content"> <div class="accordion-item__body"> <p><a href="https://massgeneralbrighamhealthplan.org/pharmacy/drug-alerts" rel="noopener">Visit the drug alert page</a><span> to find a complete list of medication recalls and safety information.</span></p> </div> </div> </li> <li class="accordion-item"> <a class="accordion-item__title" href="javascript:void(0)"> Information for Aetna Signature, PHCS, non-contracted, and Optum providers </a> <div class="accordion-content"> <div class="accordion-item__body"> <p><a href="/providers/claims-information" rel="noopener">Submit claims for Mass General Brigham Health Plan members</a></p> <p><a href="https://allwaysprovider.org/PublicSite/Home" rel="noopener noreferrer" target="_blank">A</a><a href="http://provider.massgeneralbrighamhealthplan.org" rel="noopener noreferrer" target="_blank">uthorization request form for Aetna Signature, non-contracted, and PHCS providers</a></p> <p><a href="https://www.providerexpress.com/content/ope-provexpr/us/en.html" rel="noopener noreferrer" target="_blank">Authorizations request form for Optum providers</a> </p> </div> </div> </li> <li class="accordion-item"> <a class="accordion-item__title" href="javascript:void(0)"> Information for out-of-network providers: the 2021 No Surprises Act </a> <div class="accordion-content"> <div class="accordion-item__body"> <p><span>The </span><a href="https://www.cms.gov/nosurprises">federal No Surprises Act of 2021</a><span> received rulemaking restricts certain out-of-pocket costs to commercial consumers resulting from surprise billing and balance billing. This rule goes in effect for plan, policy, or contract years starting on or after January 1, 2022, for group health plans, health insurance issuers and Federal Employees Health Benefits (FEHB) program carriers and serves to:</span><br><span> </span></p> <ul> <li>Ban balance billing for emergency services, air ambulance, and certain professional services provided by an out-of-network provider at an in-network facility. Cost sharing for these services must be determined on an in-network basis.</li> <li>Requires that patient cost sharing (copayments, co-insurance, or deductibles) for the services outlined above cannot be higher than if such services were provided by an in-network provider. Any cost sharing obligation must be based on median in-network provider rates.</li> <li>Prohibits balance billing for qualifying items or services provided by an out-of-network provider at an in-network facility unless a patient provides consent via the process required by CMS. You can<span> </span><a href="https://www.cms.gov/nosurprises">reference CMS information here</a>. Providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill the patient more than in-network cost-sharing rates. </li> </ul> <p><span>The forms and information below are provided in accordance with the federal No Surprises Act of 2021.</span><br><span> </span><br><strong>Open Negotiation Process</strong><br><span>Non-participating providers who render services in an emergency room, an air ambulance, or for certain non-participating providers (for example, an anesthesiologist or radiologist) that provide non-emergency care in a participating facility will receive a Qualified Payment Amount (QPA) when the claim pays the first time.</span><br><span> </span><br><span>If a non-participating provider rejects the QPA, they can engage in a 30-business-day open negotiation period with our designee, Clear Health Strategies, to agree on the appropriate rate for applicable items or services. You can find </span><a href="https://secure-web.cisco.com/1j4xQsFhixEiafKFitKO7khnpez63665URHMvgvltdZStu34EWijMJLuYdqxE3ozGzZ6YuMnaT8PeMO7NPxSAspcUHTCpcF8G22b8KHj4X902wBjBp2Qdx9uYnX2jZbrb8YdBjxniNh_FSksdFpvZEIH1jeyO7mpQ9v6nmSTYDPSX5dwLIbkKY03Ksc2CQemaNgwgqTi3hzYCwu-LdDXH-o99dejVZByhDeu5X-GjZTEJPRR3-U2qSSkU5uNq9qp8YcgxC35DUt_hKohBSc6BCDMBrHBP7AKx3UhSkZB5gLzcwBNQIPumjMolO1IEWpEp/https%3A%2F%2Fchsapps.clearhealthcloud.net%2Fprovider">more information from Clear Health Strategies here</a><span>.</span><br><span> </span><br><span>As a reference for the open negotiation process with Clear Health Strategies, you can review the CMS documentation </span><a href="https://www.dol.gov/sites/dolgov/files/ebsa/laws-and-regulations/laws/no-surprises-act/surprise-billing-part-ii-information-collection-documents-attachment-2.pdf">here</a><span>.</span><br><span> </span><br><strong>Independent Dispute Resolution</strong><br><span>If the Open Negotiation Process fails, either party can elect the Independent Dispute Resolution (IDR) process during the 4-business-day period beginning on the 31</span><sup>st</sup><span> business day after the start of the open negotiation period. You can learn more about initiating the IDR process, view a sample Notice of IDR Initiation, and access the necessary IDR initiation form </span><a href="https://www.dol.gov/sites/dolgov/files/ebsa/laws-and-regulations/laws/no-surprises-act/surprise-billing-part-ii-information-collection-documents-attachment-3.pdf">here</a><span>.</span><br><span> </span><br><span>Both parties must agree on the Independent Dispute Resolution entity. Failure to agree will result in an entity chosen by CMS (Centers for Medicare and Medicaid). Upon selection of the Independent Review entity, both parties will submit offers for payment as well as supporting documentation. The selected Independent Review Entity will issue a binding determination on the payment which will be considered final.</span><br><br><span>In the case of extenuating circumstances, either party may request an extension of the IDR time period by filling out </span><a href="https://www.dol.gov/sites/dolgov/files/ebsa/laws-and-regulations/laws/no-surprises-act/surprise-billing-part-ii-information-collection-documents-attachment-10.pdf">this form</a><span> and submitting it to CMS.</span></p> </div> </div> </li> <li class="accordion-item"> <a class="accordion-item__title" href="javascript:void(0)"> HIPAA companion guides </a> <div class="accordion-content"> <div class="accordion-item__body"> <p>Use these guides to help you test and setup electronic claims-related transactions with Mass General Brigham Health Plan.</p> <p><a href="https://resources.massgeneralbrighamhealthplan.org/provider/CompanionGuides/270-271CompanionGuide.pdf" rel="noopener">270/271 Eligibility Benefit Inquiry & Response</a><br><a href="https://resources.massgeneralbrighamhealthplan.org/provider/CompanionGuides/276-277CompanionGuide.pdf" rel="noopener">276/277 Claim Status Request & Response</a><br><a href="https://resources.massgeneralbrighamhealthplan.org/provider/CompanionGuides/278CompanionGuide.pdf" rel="noopener">278 Heath Care Services Review – Request for Review and Response</a><br><a href="https://resources.massgeneralbrighamhealthplan.org/provider/CompanionGuides/834CompanionGuide.pdf" rel="noopener">834 Benefit Enrollment and Maintenance</a><br><a href="https://resources.massgeneralbrighamhealthplan.org/provider/CompanionGuides/835CompanionGuide.pdf" rel="noopener">835 Electronic Remittance Advice (ERA)</a><br><a href="https://resources.massgeneralbrighamhealthplan.org/provider/CompanionGuides/837CompanionGuide(Institutional).pdf" rel="noopener">837 Institutional Billing</a><br><a href="https://resources.massgeneralbrighamhealthplan.org/provider/CompanionGuides/837CompanionGuide(Professional).pdf" rel="noopener">837 Professional Billing</a></p> </div> </div> </li> <li class="accordion-item"> <a class="accordion-item__title" href="javascript:void(0)"> Health equity resources </a> <div class="accordion-content"> <div class="accordion-item__body"> <p><strong><a href="https://resources.massgeneralbrighamhealthplan.org/providers/MGBHP_Medicaid_Member_Language_Needs_and_Language_Services_Report.pdf" rel="noopener" target="_blank">Medicaid Member Language Needs and Language Services Report</a></strong></p> <p><strong>Unconscious Bias in Medicine</strong><br><span>Sponsor: Stanford University School of Medicine</span><br><span>Number of credits: 1 credit</span><br><span>Fee: Free</span><br><a href="https://stanford.cloud-cme.com/course/courseoverview?P=8&EID=20775" target="_blank" rel="noopener noreferrer">Learn more</a><br><br><strong>Matters: The Benefits of a Diverse Workforce</strong><br><span>Sponsor: MMS</span><br><span>Number of credits: 1 credit</span><br><span>Fee: Free</span><br><a href="https://www.massmed.org/Continuing-Education-and-Events/Online-CME/Courses/Diversity-in-Medicine-Matters/Diversity-in-Medicine-Matters--The-Benefits-of-a-Diverse-Workforce/" target="_blank" rel="noopener noreferrer">Learn more</a><br><br><strong>Reflecting on Health Disparities and Moving Towards Anti-Racism in Medicine</strong><br><span>Sponsor: MMS</span><br><span>Number of credits: 1 credit</span><br><span>Fee: Free</span><br><a href="https://www.massmed.org/Continuing-Education-and-Events/Online-CME/Courses/Reflecting-on-Health-Disparities/Reflecting-on-Health-Disparities-and-Moving-Towards-Antiracism-in-Medicine/" target="_blank" rel="noopener noreferrer">Learn more</a><br><br><strong>Think Cultural Health</strong><br><span>Sponsor: HHS.gov</span><br><span>Number of credits: varies by program</span><br><span>Fee: Free</span><br><a href="https://thinkculturalhealth.hhs.gov/education/physicians" target="_blank" rel="noopener noreferrer">Learn more</a><span> </span></p> </div> </div> </li> <li class="accordion-item"> <a class="accordion-item__title" href="javascript:void(0)"> Mass General Brigham ACO Primary Care Sub-Capitation Resource Guide </a> <div class="accordion-content"> <div class="accordion-item__body"> <p><a href="https://5977230.fs1.hubspotusercontent-na1.net/hubfs/5977230/Primary%20Care%20Sub-Capitation%20Resource%20Guide-July%202024.pdf" rel="noopener" target="_blank">Mass General Brigham ACO Primary Care Sub-Capitation Resource Guide</a></p> </div> </div> </li> </ul> </div> </div> </div><!--end widget-span --> </div><!--end row--> </div><!--end row-wrapper --> </div><!--end widget-span --> </div><!--end row--> </div><!--end row-wrapper --> </div><!--end widget-span --> </div> </div> </div> <div class="container-fluid home-row6"> <div class="row-fluid-wrapper"> <div class="row-fluid"> <div 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background-position:center center;"> <h2 class="cta-block__title large-7"> Log in to access all the online provider tools </h2> <div class="cta-block__text large-7"> <div> <div> <p>On <a href="http://provider.massgeneralbrighamhealthplan.org" rel="noopener" target="_blank"><span style="text-decoration: underline;"><span style="color: #b1e4e3; text-decoration: underline;">provider.massgeneralbrighamhealthplan.org</span></span> </a>you can check eligibility, add or remove providers from your practice, and more.</p> <p><span>Not a network provider? 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