CurrentMass General Brigham Health PlanPolicy N/A

Prior Authorization, Notification, and Referral Guidelines

Defines which services require prior authorization, notification, or referrals across Mass General Brigham Health Plan products and clarifies plan-specific variations and routing for behavioral health and specialty prior authorization processes.

Policy Summary

PayerMass General Brigham Health Plan

PolicyPrior Authorization, Notification, and Referral Guidelines

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must verify member eligibility and evidence of coverage and enter prior authorizations via the Mass General Brigham Health Plan Provider Portal before scheduling services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

manyservice categories listed with PA requirements

directbehavioral health contact lines

EviCoreexternal prior authorization vendor

Optumbehavioral-health partner noted

Prior Authorization / Notification / Referral by Service

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Service PA/Notification/Referral criteria

Service-by-service prior authorization, notification, and referral requirements. Plan-specific notes and routing to medical policies or external vendors are indicated where applicable.

Service-specific prior auth/notification/referral requirements as listed below (see individual service nodes for plan variations and vendor routing).

Service list

Abortion: Prior authorization required = No.
See plan materials for additional information.
Ambulance Emergency Transportation (including inter-facility specialty care transport): Prior authorization required = No.
Non-emergent Transportation: Prior authorization required = Yes.
Covered when criteria are met; see Medical Policy: Non-emergency Medically Necessary Transportation. FOR COMMERCIAL MEMBERS ONLY.
Artificial Pancreas Device System: Prior authorization required = Yes.
See Medical Policy: Artificial Pancreas Device System.
Bariatric Surgery (Weight Loss Surgery): Prior authorization required = Yes.
See Medical Policy: Bariatric Surgery.
ALL of the following
- MGB ACO/MassHealth (MGB ACO): No prior authorization required for the 20 visits per benefit period.
- Commercial: Some commercial plans require prior authorization after the 12th visit or the 20th visit.
Continuous Glucose Monitoring Devices: Prior authorization required = No.
See Medical Policy: Continuous Glucose Monitors.
Genetic/Molecular/Genomic Testing: Prior authorization required = Yes.
Prior authorization is obtained through EviCore. Provider Service: 888-693-3211. Visit the EviCore provider portal/resource page to submit requests.
Home Health Services: Prior authorization required = No for Commercial plans.
Scope varies by plan; see Medical Policy.
Hospital at Home (HaH)/Inpatient Acute Hospital at Home admissions: Prior authorization required = Yes.
Inpatient authorization required for adult Acute Hospital at Home admissions; some specialty pharmacy drugs may require PA regardless of setting.
Infertility/Assisted Reproductive Technology: Prior authorization required = Yes.
Coverage limited for MGB ACO; employer groups may exclude services.
Inpatient Admissions (elective): Prior authorization required = Yes.
Notification and concurrent authorization rules apply; see inpatient section for timing and exceptions (e.g., newborn, preterm antepartum).
ALL of the following
- MGB ACO: Initial evaluation does not require prior authorization; subsequent visits require prior authorization.
- Commercial: Does not require prior authorization (plan-specific).
Sleep Studies including PAP therapy devices and surgical treatment for OSA: Prior authorization required = Yes.
See CareCentrix clinical criteria. CareCentrix Provider Service: 866-827-5861.
Spinal Surgery (elective): Prior authorization required = Yes.
ALL of the following
- Surgical office visits for transplant evaluation require prior authorization.
- Transplant surgery sites must be in the Mass General Brigham Health Plan Optum Transplant Network (except PPO plans). Providers not in the Optum network are considered out-of-network.
UVB Home Phototherapy Units for skin disease: Prior authorization required = Yes.
See Medical Policy: UVB Home Phototherapy Units for Skin Disease.
Vitamin D Screening and Testing: Prior authorization required = No.
Covered for adults (age ≥18) with certain documented underlying diseases or conditions; diagnosis code must be on the claim.
Other services referenced to medical policies (examples): Autologous Chondrocyte Implantation in the Knee, Bone Growth Stimulation, Cochlear Implants, Prosthetics, Panniculectomy, Rhinoplasty, Septoplasty, etc.: Prior authorization required = Yes for many such services; see the listed Medical Policies for details.

Code-specific Rules and Visit Limits

DME and code-specific PAmixed

Prior authorization requirements for DME depend on specific DME codes; providers should reference the MGBHP Code Checker for which DME requires authorization.

Chiropractic visit limits — prior authorization and per-benefit-period allowances

MGB ACO (MassHealth) allowanceNo prior authorization required for up to 20 chiropractic visits per benefit period

Commercial plan variationSome Commercial plans require prior authorization after the 12th visit or after the 20th visit

ReferenceSee Medical Policy: Chiropractic Services for clinical criteria and exceptions

Outpatient therapy initial evaluation — PA rules

MGB ACO initial evaluationInitial evaluation for outpatient physical, occupational, and speech therapy does not require prior authorization

Subsequent visits (MGB ACO)Subsequent therapy visits require prior authorization after the initial evaluation

Commercial plansCommercial members do not require prior authorization for outpatient therapy office visits; refer to plan materials for visit limits

ReferenceSee Medical Policy: Definition of Skilled Care for criteria and limits

What Providers Must Do — Authorizations, Routing, and Notifications

Prior Authorization

Prior Authorization Required / Use Provider Portal

Prior to scheduling services, providers must verify member eligibility, Provider Payment Guidelines, and the member’s evidence of coverage. Prior authorization (PA) requirements vary by product and service; services rendered without required referrals, authorizations, or notifications will not be covered. Enter Prior Authorization requests using the Mass General Brigham Health Plan Provider Portal. Rendering facilities and physicians are strongly encouraged to confirm the existence of an authorization in the Provider Portal before providing the service. Prior authorization is not a guarantee of payment.

Check member eligibility, Provider Payment Guidelines, and Evidence of Coverage before scheduling.
Enter PA requests via the Mass General Brigham Health Plan Provider Portal and verify authorizations there prior to rendering services.
Referral requirements vary by plan; the Treating Provider is the only provider authorized to make referrals to in‑network specialists when required by plan type.

Prior Authorization

Inpatient Admission Notification and Concurrent Authorization

If an inpatient admission is emergent, the provider must notify Mass General Brigham Health Plan per the plan’s notification requirements. Concurrent authorization is required following the initial notification/authorization for ongoing inpatient care. Examples: preterm (antepartum) admissions require prior authorization; postpartum admissions longer than 96 hours (4 days) require authorization. For newborns: Commercial — newborn must be enrolled in the plan for coverage and notification is required within 72 hours or by the next business day; Medicaid ACO — newborn must be enrolled and have their own Member ID for coverage.

Emergent inpatient admissions: notify the plan immediately.
Concurrent authorization is required for continued inpatient services after initial admission notification/authorization.
Preterm (antepartum) admissions require prior authorization regardless of delivery.
Postpartum admissions >96 hours require authorization.
Newborn notification/enrollment requirements vary by product (Commercial vs Medicaid ACO).

Prior Authorization

Genetic Testing Prior Authorization via eviCore

Prior authorization for Genetic/Molecular/Genomic testing is required and must be obtained through eviCore. Providers should submit genetic testing PA requests via the eviCore Provider Portal or contact eviCore Provider Services.

EviCore Provider Service: 888-693-3211
Visit the Mass General Brigham Health Plan resource page on the eviCore website and use the eviCore Provider Portal to submit prior authorization requests for genetic testing.

Key Definitions

Referral — definition and plan-specific rules

Who may request referralsThe Treating Provider is the only provider authorized to make referrals to in‑network specialists, as required by plan type

Plan variationReferral guidelines vary by plan; MGB ACO and MGB ASO members may see specialists without obtaining a referral from the health plan—check plan materials

Provider responsibilityPrior to scheduling, providers should check member eligibility and evidence of coverage to confirm referral requirements

Prior Authorization — portal entry and payment note

How to submit prior authorizationPrior authorizations should be entered using the Mass General Brigham Health Plan Provider Portal

Not a guarantee of paymentPrior authorization is not a guarantee of provider payment; authorization verification should be completed before services are rendered

Provider verificationRendering facility and physicians are strongly encouraged to verify the existence of an authorization via the Provider Portal before the service is rendered