December 2018

Read our December 2018 issue of Provider News.

From Our Chief Medical Officer, Jonathan Welch, MD

Managed care continues evolving in Massachusetts. MassHealth’s implementation of Accountable Care Organizations is redefining health care coverage by focusing on a team approach to physical and mental health, and the social determinants of health. You’ll see in this issue of Provider News how our ACO focus is expanding into identifying and assessing high risk members and delivering member-centered care planning and coordination. This is critical to helping ensure that our members receive comprehensive services in the four areas of the state where our ACO Partners are located.

Membership in our Senior Care Options program continues to grow, particularly as we increase our provider network and our collaborative efforts with providers in the five counties where we serve SCO members. More importantly, you will see in this newsletter how our member offerings support the work of providers.

We are proud to report improvements in our HEDIS measures for MassHealth and our Qualified Health Plan. This newsletter contains an article listing the measures where we exceeded the NCQA Quality Compass HEDIS benchmark, and also those measures where there are opportunities to improve. I want to thank you – our provider partners – for your dedication; our HEDIS accomplishments would not be possible without you.

Of course, I encourage you to read the entire newsletter since it contains a variety of information you will find pertinent. If you have any questions, or if you require support, please feel free to contact your dedicated BMC HealthNet Plan Provider Relations Consultant.

As we enter 2019, I wish you and your staffs a very happy new year, and I look forward to continuing our successful collaboration.

MassHealth ACO Program Update

As we continue implementing the MassHealth Accountable Care Organization (ACO) program, we are shifting our focus. Although we will continue working to ensure uncomplicated continuity of care and member transitions, now we are directing our efforts toward working closely with our ACO Partners to identify and comprehensively assess high risk members, as well as provide member-centered care planning and care coordination. Collaborating with our ACO Partners also includes further developing our quality and performance goals. In addition, we are engaging with the newly implemented behavioral health and long term services and supports Community Partner entities.

Member Re-Certification

While member transition into the new ACOs has stabilized, MassHealth’s annual member eligibility certification process is influencing continuous enrollment. This is the process by which MassHealth ensures that enrollment is open only to individuals who satisfy eligibility criteria. Wherever possible, MassHealth uses information from other government agencies to verify eligibility factors like income and citizenship. All other individuals must complete the certification process themselves. To support this process, BMC HealthNet Plan has implemented several initiatives to notify and educate members on enrollment deadlines, including mailings, outbound calls, and report sharing with our ACO partners.

ACO Growth

In an effort to ensure continued growth of the ACOs, MassHealth developed an annual process that allows ACOs to bring additional provider groups on board. Boston Accountable Care Organization was able to take advantage of this opportunity and was approved to add to its exclusive list of participants, effective January 1, 2019.

Boston Medical Center Health System’s four partners in the MassHealth ACO program are:

  • BMC HealthNet Plan Community Alliance
  • BMC HealthNet Plan Signature Alliance
  • BMC HealthNet Plan Mercy Alliance
  • BMC HealthNet Plan Southcoast Alliance

For PCPs: State Develops Resource for MassHealth ACO Community Partners

As part of the MassHealth Accountable Care Organization (ACO) program, the State has contracted with 27 Community Partners. These health care and human service organizations collaborate with the ACOs to improve health outcomes for MassHealth members with complex long term medical and/or behavioral health needs.

For the benefit of providers, MassHealth has developed a comprehensive flyer explaining the goals of a Community Partner, how members are assigned, authorizations, care plans, and a host of other topics. Learn more about Community Partners.

How to Avoid Billing Errors

As a BMC HealthNet Plan provider, we remind you to bill our members only for applicable copayments, cost-sharing and services not covered by us. Preventive services, as defined by the Affordable Care Act, are covered with no cost sharing. For a list of preventive services – and all member benefits – please review the BMC HealthNet Plan Member Handbooks (posted in the member section at The Handbooks are listed by product name and plan type. (For a listing of Senior Care Options benefits, you may click on one of the Evidence of Coverage links at You also can find preventive services information on the federal government’s website at Please note the following:

  • Balance billing of covered services is not allowed.
  • Members should not be billed for coinsurance or a deductible until the claim has processed. This will ensure that members are billed accurately. If a member has a cost-share, it will be reflected in the remittance advice.

Making It Easier for Providers

We want to lessen your administrative burden as much as possible. Toward that end you can call our provider line at 888-566-0008 to verify the following and help ensure accuracy:

  • Member benefit plan, benefits and eligibility
  • Member’s PCP assignment
  • Provider participation status (before you render services)

We also furnish this information when you complete our prior authorization process.

Wraparound Benefits

Please note: MassHealth members have certain additional benefits covered directly by MassHealth; these are known as “wraparound” benefits. You should bill MassHealth directly for wraparound benefits. For information on wraparound benefits, please call the MassHealth Customer Service Center at 888-841-2900 (TTY/TDD 800-497-4648).

HEDIS® Scores Increase in 18 Measures

Healthcare Effectiveness Data and Information Set (HEDIS®), developed by the National Committee for Quality Assurance (NCQA), is a nationally standardized set of measures related to important areas of care and service. HEDIS scores allow BMC HealthNet Plan to monitor how many members receive the services they need, and how we compare to national benchmarks.

MassHealth and Qualified Health Plan (QHP) Clinical Improvements

Thanks to your hard work, the following HEDIS 2018 (calendar year 2017) measures exceeded the 2018 NCQA Quality Compass HEDIS Medicaid HMO 90th Percentile Benchmark.

MassHealth (including CarePlus) Measures

  • Initiation and Engagement of AOD Treatment - Engagement (all ages)
  • Pharmacotherapy for COPD - Systemic Corticosteroids
  • Weight Assessment and Counseling - Nutrition Counseling
  • Weight Assessment and Counseling - Physical Counseling
  • Use of Imaging Studies for Low Back Pain
  • Chlamydia Screening in Women
  • Comprehensive Diabetes Care - Eye Exams
  • Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
  • Breast Cancer Screening
  • Cervical Cancer Screening
  • Appropriate Testing for Children with Pharyngitis
  • Appropriate Treatment for Children with Upper Respiratory Infection
  • Childhood Immunization Status (Combo 10)
  • Lead Screening in Children
  • Follow-up After Emergency Department Visit for Mental Illness (7-day rate)
  • Follow-up After Emergency Department Visit for Mental Illness (30-day rate)
  • Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependencies (7-day follow-up)
  • Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependencies (30-day follow-up)

QHP Measures

  • Follow-Up After Hospitalization for Mental Illness (7-day rate)
  • Weight Assessment and Counseling - Physical Counseling
  • Comprehensive Diabetes Care - HbA1c Testing
  • Comprehensive Diabetes Care - HbA1c <8%
  • Postpartum Care
  • Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
  • Breast Cancer Screening
  • Use of Imaging Studies for Low Back Pain

MassHealth and Qualified Health Plan Clinical Opportunities for Improvement

While we acknowledge these achievements, we will continue working toward improving other important measures. The following measures are below the 2018 NCQA Quality Compass HEDIS Medicaid HMO 50th Percentile Benchmark, so we have an opportunity to improve.

MassHealth (including CarePlus) Measures

  • Adherence to Antipsychotic Medications for People with Schizophrenia
  • Diabetes Monitoring for People with Diabetes and Schizophrenia
  • Asthma Medication Ratio
  • Statin Therapy for Patients with Cardiovascular Disease - 80% Adherence
  • Statin Therapy for Patients with Diabetes - 80% Adherence
  • Use of Multiple Concurrent Antipsychotics in Children and Adolescents
  • Comprehensive Diabetes Care - HbA1c < 8%
  • Antidepressant Medication Management - Continuation Phase
  • Antidepressant Medication Management - Acute Phase

QHP Measures

  • Cervical Cancer Screening
  • Initiation and Engagement of AOD Treatment - Initiation (all ages)
  • Initiation and Engagement of AOD Treatment - Engagement (all ages)
  • Adult BMI Assessment
  • Comprehensive Diabetes Care - Nephropathy Screening

You Can Assist Us

Here are some steps you can take to help us close gaps in care and improve our HEDIS rates even further:

  • Encourage your patients to schedule regular well visits and appropriate follow-up visits
  • Educate your patients on the importance of medication adherence
  • Remind your patients to complete ordered tests and procedures in a timely manner
  • Use every patient encounter to review and provide needed care
  • Remind your patients to ask all providers involved in their health care to send you consultation reports and test results to improve continuity of care
  • Submit claims with proper billing codes. For guidance, please refer to this HEDIS 2018 Documentation & Coding Tips for Providers document on our website.

It’s Important to Notify Us of Provider Demographic Changes

Please remember to let us know when you have demographic changes within your practice, particularly as they relate to your payment information. Out-of-date information delays your payments and can result in lost checks.

If you have a change in your remittance address or Tax Identification Number, please send to us – as soon as possible – a W9 and a Provider/Termination Change Form. Mail the information to:

BMC HealthNet Plan
Provider Processing Department
529 Main Street, Suite 500
Charlestown, MA 02129

Or you may email it to

Demographic changes that you need to notify us about include:

  • Mailing address
  • Tax Identification Number or entity affiliation (W-9 required)
  • Group name or affiliation
  • National Provider Identifier
  • Telephone and/or fax number
  • Termination or expiration
  • Provider updates in panel status

Administrative Support Just a Click Away

You can conduct a number of important administrative functions with your secure login. This can save you time, reduce costs, and also improve patient satisfaction because you’ll be able to spend more time with them. With your login you can:

  • Submit prior authorization requests with the ability to electronically attach clinical records. You also can view the status of a prior authorization request that has been submitted electronically or by fax, phone or postal mail.
  • Check claims status. You can view claims status with enhanced detail information, including claims pending adjudication.
  • Verify member eligibility
  • Check PCP assignment
  • View remittance history
  • Download useful reports such as your daily inpatient census, PCP panel, emergency room frequent users, and other pertinent reports

Does the Service Need Prior Authorization?

We also offer additional resources to help you determine if services require prior authorization; see our online Prior Authorization Matrix. In addition, our HCPCS Lookup Tool and CPT Code Lookup Tool allow you to type in a code to find out whether the service or procedure requires a prior authorization in the inpatient or outpatient setting.

Documents Available Without a Login

Save time by accessing the following BMC HealthNet Plan documents, located on the Providers page at without a login:

Click on the following links to access the respective documents:

Supporting Providers Through Our SCO Membership Growth

In September, membership in BMC HealthNet Plan’s Senior Care Options (SCO) program reached an important milestone: over 1,000 members. In 2018 alone we experienced a 116% growth rate as of November 1. We first launched our SCO program in Suffolk County in January 2016; in 2018 we expanded it to Hampden, Bristol, Barnstable, and Plymouth counties.

Among the drivers of this steady membership increase are strengthening our provider network, leveraging partnerships we have with community organizations, and increasing our community outreach staff. Of course, our membership growth is also a testament to the quality care you furnish each day, and for that we are grateful.

Supporting Health Care Providers by Supporting SCO Members

We want to help our SCO members to be as healthy as possible for as long as possible. This benefits them and their health care providers by helping ensure compliance and follow-up. For example, we offer SCO members:

  • Assistance with scheduling specialty care appointments
  • Access to transportation to and from medical appointments, which reduces cancellation rates
  • Care manager attendance at appointments, when necessary, to help reinforce provider instructions
  • Follow-up after appointments to ensure that prescriptions are filled and taken properly
  • Medication reviews to identify possible overlaps and side effects
  • Coverage for over-the-counter medications

In 2019, continued growth of our SCO program looks favorable as we broaden our provider network and focus on the new counties where we have expanded. We also anticipate working with our Accountable Care Organization partners in moving our SCO program forward.

Text Messaging Program Improves Member Engagement

For nearly two years we have been partnering with HealthCrowd, a health care communications technology vendor, to engage our members through text messaging. The goal is to instruct them on the importance of preventive health screenings and managing chronic conditions. Members receive educational materials, reminders about needed care, phone numbers for their primary care providers, and links to additional online resources such as care management, and pertinent website addresses.

What We Found

Our most current research indicates improvements in member behaviors resulting from the texting program. For example, there were increased closures in care gaps, which translate to increased member engagement. In addition, there was an above average reactivity rate of 13% (reactivity is the percent of members who interacted with BMC HealthNet Plan through text messaging). We are pleased to report that this rate is higher than HealthCrowd’s average range. As shown in the charts below, text messaging also led to higher improvements among participants compared to non-participants for certain HEDIS quality measures.

MassHealth Cervical Cancer Screening and Asthma Medication Ratios

Qualified Health Plan Diabetes Nephropathy Screening and Cervical Cancer Screening

The charts below display results of satisfaction surveys conducted at the end of each text messaging campaign. Members are extremely satisfied with this new form of communicating information about preventive screenings and resources.

Texting Survey Responses

Moving Forward

We continue analyzing and enhancing the texting program. Messages now are sent to all participants throughout the year that align with national health observances such as breast, cervical and colon cancer screening, the National Smoke Out and other health and wellness topics. We also use reactivity data to improve member engagement in the program and will continue to do so as we learn more about how members respond to the messages. In addition, we are exploring new methods of enrolling members into the program, and we are completing a pilot with the Qualified Health Plan population to assess how members respond to invitations to the program through an initial text.

You Can Tell Our Members About It

Text messaging is open to all BMC HealthNet Plan members, except those in our Senior Care Options program. During office visits, we hope you encourage our members to register for the text messaging program. For more information, visit our Text Messaging page.

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