Provider Payment Guidelines
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Provider Payment Disputes Page 1
Provider Payment Disputes
Policy
The terms of this policy set forth the guidelines for reporting the provision of care rendered by Mass
General Brigham Health Plan participating providers, including but not limited to, use of standard
diagnosis and procedure codes in compliance with HIPAA (Health Information Portability and
Accountability Act) medical transaction code set standards.
Reimbursement
Providers are reimbursed in accordance with the plan’s network provider reimbursement or contracted
rates. Claims are subject to payment edits that are updated at regular intervals.
Covered services are defined by the member’s benefit plan. The manner in which covered services are
reimbursed is determined by the Mass General Brigham Health Plan Payment Policy and by the
provider’s agreement with Mass General Brigham Health Plan . Member liability amounts may include
but are not limited to copayments; deductible(s); and/or co-insurance; and will be applied dependent
upon the member’s benefit plan.
Various services and procedures require referral and/or prior authorization. Referral and prior
authorization requirements can be located here.
Please reference procedure codes from the current CPT, HCPCS Level II, and ICD-10-CM manuals, as
recommended by the American Medical Association (AMA), the Centers for Medicare & Medicaid
Services (CMS), and the American Hospital Association. CMS and the AMA revise HIPAA medical codes
on a pre-determined basis, including changes to CPT, HCPCS, and ICD-10 codes and definitions.
Please refer to the CMS or CPT guidelines for requisite modifier usage when reporting services. The
absence or presence of a modifier may result in differential claim payment or denial.
Mass General Brigham Health Plan reviews claims to determine eligibility for payment. Services
considered incidental, mutually exclusive, integral to the primary service rendered, or part of a global
allowance, are not eligible for separate reimbursement. This is the General Coding and Billing PPG. All
claims are subject to audit, and Mass General Brigham Health Plan may request medical records from
the provider.
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Requesting an Administrative Appeal
As described in the Billing Guidelines Section of the Provider Manual, providers can request a review and
possible adjustment of a previously processed claim within 90 days of the Explanation of Payment (EOP)
date on which the original claim was processed. If the provider is not satisfied with the outcome of the
request, an appeal can be submitted to Mass General Brigham Health Plan’s Appeals and Grievances
Department.
An appeal is a request for reconsideration of a claim denial by to Mass General Brigham Health Plan.
Appeal requests must be submitted in writing within one of the following timeframes:
• 90 days of receipt of the Mass General Brigham Health Plan Explanation of Payment (EOP)
• 90 days of receipt of the EOP from another insurance, when applicable
• 90 days of the date of the claim’s adjustment letter
The appeal must include additional, relevant information and documentation to support the request.
Requests received beyond the 90-day appeal requests filing limit will not be considered.
When submitting a provider appeal, please use the Request for Claim Review Form
Provider Audit Appeals/General Claims Audit Appeal Requests
For claims audited and adjusted post-payment, if the provider disagrees with the reason for the
adjustments, a letter of appeal or a completed Mass General Brigham Health Plan Provider Audit Appeal
Form may be submitted to Mass General Brigham Health Plan’s Appeals Department within 90 days of
the EOP.
The request must be accompanied by comprehensive documentation to support the dispute of relevant
charges. To the extent that the provider fails to submit evidence of why the adjustment is being
disputed, the provider will be notified of Mass General Brigham Health Plan ’ inability to thoroughly
review the request. The provider can resubmit the appeal within the 90 days EOP window. The appeal’s
receipt date will be consistent with the date Mass General Brigham Health Plan received the additional
documentation.
Mass General Brigham Health Plan will review the appeal and, when appropriate, consult with Mass
General Brigham Health Plan clinicians or subject matter experts in the areas under consideration. The
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appeal request will be processed within 30 calendar days from Mass General Brigham Health Plan’s
receipt of all required documentation.
The appeal determination will be final. If the appeal request is approved, Mass General Brigham Health
Plan will adjust the claims in question within 10 calendar days of the provider’s notification of the final
determination.
Claim Adjustments/Requests for Review
Request for a review and possible adjustment of a previously processed claim (not otherwise classified
as an appeal) should be submitted to the Claim Adjustment Requests mailbox within 90 days of the EOP
date on which the original claim was processed. All such requests should be submitted by completing a
Request for Review Form and including any supporting documentation, with the exception of
electronically submitted corrected claims. When submitting a provider appeal, please use the Request
for Claim Review Form
Corrected Claims and Disputes of Duplicate Claim Denials
Mass General Brigham Health Plan accepts both electronic and paper corrected claims, in accordance
with guidelines of the National Uniform Claim Committee (NUCC) and HIPAA EDI standards. Corrected
claims must be submitted with the most recent version of the claim to be adjusted. must be received no
later than 60 days from the date of the original adjudication. Any payment disputes received after that
time will not be considered. Mass General Brigham Health Plan will not accept handwritten claims, or
handwritten corrected claims.
Provider payment disputes that require additional documentation must be submitted on paper, using
the Request for Review Form. Request for Claim Review Form
Appealing a Behavioral Health Service Denial
Optum is Mass General Brigham Health Plan ’ Behavioral Health Partner and is delegated all Behavioral
Health (BH) related matters, including grievances/complaints and appeals. All BH related
grievances/complaints and appeals must be submitted to Optum directly
For more information, please refer to the Behavioral Health provider manual or contact Optum
Late Charges
Mass General Brigham Health Plan accepts corrected claims to report services rendered in addition to
the services described on an original claim. Mass General Brigham Health Plan will not accept separate
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claims containing only late charges. Mass General Brigham Health Plan will not accept Late Charge
claims from institutional (facility) providers, including, but not limited to hospitals; ambulatory surgery
centers; skilled nursing facilities (SNF); hospice; home infusion agencies; or home health agencies.
Filing Limit Adjustments
To be considered for review, requests for review and adjustment for a claim received over the filing limit
must be submitted within 90 days of the EOP date on which the claim originally denied. Disputes
received beyond 90 days will not be considered.
If the initial claim submission is after the timely filing limit and the circumstances for the late submission
are beyond the provider’s control, the provider may submit a request for review by sending a letter
documenting the reason(s) why the claim could not be submitted within the contracted filing limit and
any supporting documentation. Documented proof of timely submission must be submitted with any
request for review and payment of a claim previously denied due to the filing limit. A completed
Request for Review Form must also be sent with the request. Request for Claim Review Form
Related Mass General Brigham Health Plan Payment Guidelines
General Coding and Billing
Inpatient Hospital Admissions
Modifiers
Provider Manual/Section8_Billing Guidelines (Commercial)
Provider Manual/Section10_Appeals And Grievances (Commercial)
Provider Manual/Section3_Provider Management (Commercial)
References
American Medical Association (AMA) Current Procedural Terminology (CPT)
CMS/HIPAA Information Series
HCPCS Level II
ICD-10-CM
Publication History
Topic: Provider Payment Disputes
Owner: Network Management
December 24, 2020 Original Documentation
December 28, 2023 Document rebrand
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January 1, 2024 Annual review, no policy change
This document is designed for informational purposes only. Claims payment is subject to member eligibility and 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
a conflict between this payment guideline and the provider’s agreement, the terms and conditions of the provider’s agreement
shall prevail. Payment policies are intended to assist providers in obtaining Mass General Brigham Health Plan's payment
information. Payment policy determines the rationale by which a submitted claim for service is processed and paid. Payment
policy formulation takes into consideration a variety of factors including: the terms of the participating providers ‘contract(s);
scope of benefits included in a given member’s benefit plan; clinical rationale, industry-standard procedure code edits, and
industry-standard coding conventions.
Mass General Brigham Health Plan includes Mass General Brigham Health Plan, Inc., and Mass General
Brigham Health Plan Health Partners Insurance Company.
