CurrentMass General Brigham Health PlanPolicy 039

Medical Policy Out of Network Providers

Defines Mass General Brigham Health Plan criteria and procedures for authorizing and reimbursing services provided by out-of-network providers across Commercial, MassHealth, OneCare, PPO, ACO, and SCO products, including continuity of care timeframes, required provider agreements, travel/distance guidelines, exclusions, and special-case rules (pregnancy, terminal illness, emergencies, cancer/pediatric facilities).

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Policy Out of Network Providers

Policy CodePolicy 039

Change TypeAd-hoc & annual revisions (most recent: January 2026)

Effective DateDec 1, 2015

Next Review Date

Key ActionObtain prior authorization and, when required, a signed letter of agreement from out-of-network providers and follow plan-specific notification rules (e.g., emergency inpatient notification within 24 hours or next business day).

SourceLink

POLICY UPDATE CHANGES

January 2026: Ad-hoc review updated prior authorization table and clarified coverage for OneCare and SCO members.

2024: Clarified 'primary residence' under Distance Guidelines.

2023: Annual update; no changes.

June 2022: Multiple edits including addition of 'Commercial and Qualified Health Plan' verbiage and alignment of MassHealth language.

January 2022: Added definition of 'serious' to comply with No Surprises Act.

4Member continuity timeframe variants

4Distance/travel guideline types

8Exclusion categories

1Material changes flagged

Coverage Summary

This policy defines Mass General Brigham Health Plan's rules for authorizing and reimbursing services provided by Out‑of‑Network (OON) providers across Commercial, MassHealth, OneCare, PPO, ACO, and SCO products. It covers when OON care may be authorized (including required Letter of Agreement (LOA) and adherence to plan rules), product‑specific continuity timeframes (e.g., PCP continuation ≤ 90 days for Commercial/Qualified Health Plans and PCP continuation ≤ 30 days for MassHealth/OneCare/SCO), treatment‑specific exceptions (pregnancy postpartum coverage, terminal illness, acute/serious and complex conditions up to 90 days or until active treatment ends), and product‑dependent prior authorization/notification requirements.

Key thresholds / timeframes

Primary care continuation (Commercial/Qualified Health Plan)<= 90 days from date of enrollment or up to 90 calendar days after provider termination

Primary care continuation (MassHealth/OneCare/SCO)<= 30 days from date of enrollment or up to 30 calendar days after provider termination

Acute or serious & complex condition continuation<= 90 days from date of enrollment or up to 90 calendar days, or until current period of active treatment ends, whichever comes first

Obstetrical/gynecological and specialist distance/time guidelinewithin 20 miles or 40 minutes travel time

Rehabilitation hospital services distance/time guidelinewithin 30 miles or 60 minutes travel time

Acute inpatient services distance/time guidelinewithin 20 miles or 40 minutes travel time

Urgent care services distance/time guidelinewithin 15 miles or 30 minutes travel time

Authorization & Continuity Criteria

Continuity of Care — Newly Enrolled Members

Coverage for existing treatment from OON providers for newly enrolled members is authorized under product-specific timeframes:

Commercial / Qualified Health Plan

Member may continue to receive care from a primary care provider (PCP) for up to 90 days from the date of enrollment.<= 90 days
Member may continue to receive care to treat or manage an acute or serious and complex medical condition for up to 90 days from the date of enrollment.<= 90 days
Member in second or third trimester of pregnancy may continue to receive care with the treating provider through the first postpartum visit.

Provider Requirements & Operational Steps

Prior Authorization

Prior authorization required for OON services (product-dependent)

Prior authorization is required for out-of-network (OON) providers for specified products. Authorization is required for Commercial HMO, Mass General Brigham ACO, OneCare, and SCO. PPO may be subject to different rules and services accessed under the PPO may be subject to prior authorization per the plan's terms. Emergency inpatient admissions require notification within 24 hours or by the next business day.

Products: Authorization required — Commercial HMO, Mass General Brigham ACO, OneCare, SCO; PPO plan rules differ and may allow nonpreferred provider access subject to plan conditions.
Emergency inpatient admission notification: notify within 24 hours or by the next business day (each subsequent day of care requires prior authorization).

Documentation Required

Notification for emergency inpatient admissions

Regulatory References / Citations

Policy References / Regulatory Citationsmixed

211 CMR 52.00	Managed Care Consumer Protections and Accreditation of Carriers
211 CMR 153.00	Continuity of Care Access to Comprehensive Cancer Centers, Pediatric Hospitals, and Pediatric Specialty Units for Limited/Tiered Network Plans
958 CMR	Health Policy Commission, CMR 958.300: Health Insurance Consumer Protection
Public Law 116-260	No Surprises Act (2020)
130 CMR 450.204	MassHealth medically necessary services definition (referenced)

Background & Definitions

Purpose: to operationalize statutory consumer protections including the No Surprises Act and applicable Massachusetts regulations so members retain continuity of medically necessary care when receiving services from OON providers. The policy aligns with state requirements (for example, 958 CMR continuity provisions and other cited regulations) and MassHealth standards to ensure continuity where disruption would pose undue risk. It clarifies provider obligations (LOA, acceptance of specified reimbursement, adherence to prior authorization and treatment plan requirements), product‑specific notification and authorization processes, and aims to preserve uninterrupted access to medically necessary services while protecting plan and member interests.

Term	Definition
Out of Network Provider	Care or services delivered by providers who are not part of Mass General Brigham Health Plan's network; providers include clinicians and facilities.
Postpartum Period	The period following delivery usually between 21 and 56 days after delivery when the mother has a postpartum checkup.
Serious Disease	A condition that is life threatening or is likely to lead to serious or permanent disability if left untreated.
Terminal Illness	An illness that is likely, within a reasonable degree of medical certainty, to cause death within six months.
Voluntary Provider Termination	Termination based on the provider's decision not to continue participation after providing prior written notice as specified in the provider's contract.

Not Covered / Exclusions

Services will not be authorized or reimbursed under the following explicit exclusions: when the stated coverage criteria are not met; when the service is not a covered benefit under the member's plan; when a qualified network provider is available and a newly enrolled member requests continuation beyond the allowed timeframe; when the member travelled outside the Plan enrollment area for a reasonably foreseeable need; when the member can safely return to the service area without intractable pain or risk of deterioration or permanent impairment; when the OON provider lacked required prior authorization (PPO plan excepted); and when Mass General Brigham Health Plan previously terminated the OON provider for quality deficiencies or fraud.

Policy Revision History

January 2026material_revisionLatest

Ad-hoc review updated prior authorization table and clarified coverage language for OneCare and SCO members.

2024revision

Annual update clarified the definition of 'primary residence' under Distance/Travel Guidelines.

2023administrative_review

Annual update with no policy changes.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Policy Out of Network Providers

Policy CodePolicy 039

Change TypeAd-hoc & annual revisions (most recent: January 2026)

Effective DateDec 1, 2015

Next Review Date

SourceLink

On This Page

Member with a terminal illness may continue care by the treating provider up to the member's death.until death

MassHealth / OneCare / SCO

Member may continue to receive care from a primary care provider (PCP) for up to 30 days from the date of enrollment.<= 30 days
Member may continue to receive care to treat or manage an acute or serious and complex medical condition for up to 90 days from the date of enrollment.<= 90 days
New members in any trimester of pregnancy may continue to receive care with the OON treating provider through the postpartum period.postpartum period
Member with a terminal illness may continue care by the treating provider up to the member's death.until death

Emergency inpatient admissions must be notified to the plan within 24 hours or by the next business day. For each subsequent day of inpatient care following the emergency admission, prior authorization is required.

Notification timing: within 24 hours or by the next business day.
Subsequent days: each subsequent day of care requires prior authorization.

Documentation Required

Letter of Agreement (LOA) and treatment documentation

OON providers may be required to sign a Letter of Agreement (LOA) that outlines payment details and agree to plan conditions. Disenrolled providers must accept reimbursement at rates applicable prior to the notice of disenrollment as payment in full and must not impose cost-sharing on the member that would exceed what could have been imposed had the provider not been disenrolled. Providers must provide necessary medical information and adhere to the plan's policies and procedures, including prior authorization and approved treatment plans.

LOA: may be required to outline payment terms and communication with the member.
Disenrolled provider reimbursement: accept prior applicable rates as payment in full and not impose greater cost-sharing.
Documentation and compliance: provide necessary medical information and adhere to plan policies (referrals, prior authorizations, treatment plans).

Billing Rule

Cost sharing application for authorized OON services

When OON services are authorized, in-network cost sharing applies for covered services with the authorized OON provider during the approved periods for HMO and for PPO per plan-specific provisions. For the PPO plan, in-network cost sharing applies only during the approved authorization periods; after those periods expire, out-of-network cost sharing applies.

HMO: in-network cost sharing applies for covered services with an authorized OON provider.
PPO: in-network cost sharing applies only during approved authorized periods; after expiration, out-of-network cost sharing applies and out-of-pocket costs are generally higher.

Denial Risk

Denial risk if conditions not met or exclusions apply

Services may be denied or not reimbursed when required conditions or exclusions apply. Common denial risks include unmet authorization or coverage criteria, services not covered by the member's plan, availability of a qualified network provider when continuation beyond allowed timeframes is requested, member travel outside the enrollment area for a foreseeable need, member being physically able to safely return without intractable pain or deterioration, the OON provider was not prior authorized (PPO exception noted), or the provider's contract was previously terminated for quality deficiencies or fraud.

No coverage if criteria not met or service not a covered benefit.
Denied if a qualified network provider is available and continuation beyond allowed timeframe is requested.
Denied if member traveled outside the plan enrollment area for a foreseeable need or can safely return without deterioration.
Denied if OON provider was not prior authorized (PPO exclusion applies) or provider was terminated for quality/fraud.

June 2022revision

Ad-hoc review added 'Commercial and Qualified Health Plan' verbiage, edited MassHealth language for alignment with MassHealth requirements, and made other edits to coverage language.

January 2022regulatory_compliance_addition

Ad-hoc update to comply with the No Surprises Act; added definition of 'serious'.