CurrentMass General Brigham Health PlanPolicy N/A

Annual Updates to Physician and Outpatient Hospital Reimbursement

Governs the timing and basis for updating physician, outpatient hospital and related fee schedules for Mass General Brigham Health Plan products (Commercial, Medicare Advantage, and Medicaid) and describes reimbursement principles affecting providers.

Policy Summary

PayerMass General Brigham Health Plan

PolicyAnnual Updates to Physician and Outpatient Hospital Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionLocate referral and prior authorization requirements on the provider portal before submitting services that may require authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 1New codes effective (Commercial)

Jul 1RVU updates effective (Commercial)

QuarterlyFee schedule review frequency

30 daysMassHealth change incorporation

2018–2025Publication history

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.

Reimbursement Criteria and Processing Rules

General reimbursement and claims processing principles that determine payment eligibility and amounts.

Claims payment is subject to member eligibility, benefits on the date of service, coordination of benefits, referral/authorization/notification and utilization management guidelines when applicable, adherence to plan policies and procedures, claims editing logic, and provider contractual agreement.

In the event of conflict between this payment guideline and the provider's agreement, the terms and conditions of the provider agreement prevail.

Providers are reimbursed in accordance with the plan's network provider reimbursement or contracted rates; member liability (e.g., copayments, deductibles, coinsurance) is applied based on the member's benefit plan.

Claims are subject to payment edits and audits; medical records may be requested. Services considered incidental, mutually exclusive, integral to the primary service rendered, or part of a global allowance are not separately reimbursable.

Refer to current CPT, HCPCS Level II, and ICD-10-CM code sets and to CMS/CPT guidance for requisite modifier usage; absence or presence of a modifier may result in differential payment or denial.

Fee schedule and pricing principles: Commercial physician reimbursement is based on CMS RVUs and the plan's conversion factors; outpatient reimbursement is based on CMS OPPS and ancillary/surgical fee schedules; Medicaid uses MassHealth published rates when available or relates pricing to CMS when not. Drug, vaccine, and toxoid reimbursement follows CMS Part B levels and is updated quarterly; if no CMS pricing exists, pricing is set in relation to AWP.

Timing for updates: New commercial outpatient and related codes effective January 1 annually; existing CPT/HCPCS RVU changes effective July 1 annually; fee schedules and drug/vaccine reimbursements reviewed quarterly; MassHealth changes are incorporated into Medicaid fee schedules within 30 days of notification.

Referenced Code Sets and Modifier Guidance

Referenced code setsmixed

CPT, HCPCS Level II, ICD-10-CM

Procedure and diagnosis code sets referenced for claim submission and reimbursement.

Modifier usage

Modifier guidanceFollow CMS or CPT guidelines for requisite modifier usage when reporting services; absence or presence of a modifier may result in differential claim payment or denial.

Impact on paymentModifiers can change adjudication results and may lead to reduced payment or denial if omitted or applied incorrectly.

Source for specific rulesRefer to CMS and CPT manuals for modifier definitions, correct usage, and reporting conventions.

Claims review and auditClaims are reviewed for correct coding and modifier use; medical records may be requested during audits.

Related guidanceSee General Coding and Billing guidance within the Plan documentation for additional modifier and bundling rules.

Prior Authorization, Referrals, and Provider Requirements

Prior Authorization

Obtain required referrals and prior authorizations via the provider portal

Various services and procedures require referral and/or prior authorization; referral and prior authorization requirements can be located on the provider portal. Providers should confirm authorization/referral requirements prior to delivering services to avoid potential claim denials or nonpayment.

Check the provider portal for specific referral and prior authorization requirements for the service being requested.
Obtain required prior authorization or referral before rendering services to ensure claims are eligible for payment.

Update Frequency and Timing Definitions

Fee schedule update timing

New code effective date (Commercial/outpatient)New codes added to Commercial physician, ambulance, drug, DME, laboratory, radiology, and outpatient hospital fee schedules are effective January 1 each year.

Existing CPT/HCPCS RVU updates (Commercial)Updates to existing CPT and HCPCS codes to incorporate RVU changes take effect annually on July 1.

Quarterly reviews and drug updatesFee schedules and reimbursement for drugs, vaccines, and toxoids are reviewed and updated on a quarterly basis based on CMS Part B drug notices.

Medicare Advantage and Medicaid timingMedicare Advantage fee schedules updated as directed by CMS; Medicaid (MassHealth) rates incorporated within 30 days of notification from MassHealth.

Ongoing review cadenceMass General Brigham Health Plan reviews physician and outpatient fee schedules quarterly to ensure they remain current and consistent with industry standards.