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Prior AuthorizationsMassHealth or MBHP must approve certainhealth care and pharmacy services beforeyou get them. This is called priorauthorization (PA). During the PA process,MassHealth or MBHP determines if therequested service is medically necessary foryou. If you want to know if you need a PAfor a service or medication, you can: ask your PCP;check the Covered Services Liston the all the MassHealth Customer ServiceCenter for questions about healthcare services and medications;call MBHP for questions aboutbehavioral health services; orgo to www.mass.gov/druglist to seea list of medications that require PA.Emergency Services do not require priorauthorization. You can use any emergencyroom or other setting to receive EmergencyServices.a decision on your provider’s request withinthe following time frames: Pharmacy (medicine): 24 hoursNon-emergency transportation: 7calendar days (or the number ofdays needed to avoid serious risk tothe health or safety of the member)Private-duty-nursing services: 14calendar daysDurable medical equipment: 15calendar daysAll other services: 21 calendar daysIf MassHealth approves the PA request,they will send a letter to your provider soyou can get the services or medication.You will also get a letter from MassHealthif they: do not authorize any of therequested services or medication;approve only some of the requestedservices or medication; ordo not approve the full amount,time period, or scope of the servicesor medication requested.If you disagree with a decision made abouta request for PA, you can appeal thedecision. Read more about appeals later inthis Handbook.If MassHealth does not act on a request forPA within the time frames above, you canfile an appeal with the Board of Hearings.Read more about appeals later in thisHandbook.MassHealth Prior AuthorizationsMassHealth will not pay for a service thatneeds PA if approval was not given.When your PCP or another medical providerthinks you need a service or medicationthat needs PA, your provider will askMassHealth for PA. MassHealth must makeAll medical and surgical elective (nonemergency) admissions to an acute hospitalmust be approved by MassHealth. If youFor questions or concerns, call the Partners HealthCare Choice ACO Customer Service Centerat 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:www.massgeneralbrigham.org/MassHealthACO9

plan to be hospitalized for an electiveprocedure, your doctor or nurse will submitthe necessary paperwork to make a requeston your behalf. If MassHealth approves therequest, they will notify you and yourprovider and you can get the requestedservices.If MassHealth does not approve thehospitalization, they will send you a lettertelling you so. You have the right to appealthe decision to the Board of Hearings.grievance if you don’t agree with MBHP’sreasons. Read more about filing a grievancelater in this Handbook. If MBHP approvesthe request, MBHP will pay for the service.You will get a letter if MBHP: MBHP Prior AuthorizationsWhen your behavioral health providerthinks you need a service that needs PA,your provider will ask MBHP for the PA.MBHP must make a decision on yourprovider’s request within 14 calendar daysunless you, your provider, or MBHP asks formore time. This can be for up to 14 extracalendar days. MBHP can ask for more timeonly if it’s in your best interest and moreinformation is needed.If your provider or MBHP thinks that taking14 days to decide the request will put yourhealth at risk, MBHP will make a decisionwithin three working days. This time framemay be extended by an additional 14calendar days, if you, your provider, orMBHP asks for more time. MBHP can askfor more time only if it is in your bestinterest and more information is needed.Any time that MBHP asks for more time,MBHP will send you a letter to let you knowthe reasons. You have the right to file a10does not authorize any of therequested services;approves only some of therequested services; ordoes not approve the full amount,time period, or scope of the servicesrequested.You have the right to appeal the decision toMBHP. Also, if MBHP does not act on therequest within the time frames above, youcan file an appeal with MBHP. Read moreabout filing an MBHP internal appeal laterin this Handbook.MBHP will not pay for a service that needsPA if approval was not given.Reporting Fraud:If you believe that a health care provider,doctor, hospital, or member is misusingMassHealth, then you can report thesituation to the MassHealth Fraud Hotlineby calling 1-877-437-2830.Advance Directives:An advance directive is a statement thatyou write or sign that indicates who you

choose to make health care decisions foryou, and which health care treatment youdo or do not want if you get sick or injuredand can’t talk or write.There are two kinds of advance directives: ahealth care proxy and a living will.A health care proxy is your writtenpermission for a family member or friend tomake health care decisions for you in caseyou cannot make them yourself. Thisperson is called your “agent” or “proxy.”A living will lets you describe what kind ofcare you want or do not want if you cannotmake health care decisions. For example,you may not want to be kept alive using lifesupport. Your living will helps your healthcare proxy make decisions for you. If you donot have a health care proxy or if yourhealth care proxy is not available, the livingwill can help your providers care for you.If you choose to sign a health care proxy orliving will, you can change your mind at anytime and write and sign new ones.You should talk to a health care provider tolearn more about advance directives. Formore information, you can also callMassHealth Customer Service or MBHP.For questions or concerns, call the Partners HealthCare Choice ACO Customer Service Centerat 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:www.massgeneralbrigham.org/MassHealthACO11

SECTION TWO: Your Partners HealthCare Choice MassHealth ACOTopics in this section: Your MassHealth ACO Your ID Card Your Provider Network Out-of-Network Services Your MassHealth ACO Benefits When to Call Your ACO 24/7 Clinical Advice and Support Line Changing Your PCPhealthy and better understand your care.In some cases, you may also work withadditional staff to coordinate your carewhether it is medical care, behavioralhealth care, or other care services relatedto your health.You can visit this link for more COYour MassHealth ACO:Your primary care provider (PCP) is part of anew program: Partners HealthCare Choice.Partners HealthCare Choice is a MassHealthAccountable Care Organization (ACO).ACOs are groups of doctors, hospitals, andother health care providers who cometogether to provide coordinated, highquality care to MassHealth members. Thisnew program will help your PCP provideyou with more coordinated care. Yourbenefits, doctors, and other health careproviders will remain the same.Why the Partners HealthCare Choice ACO isImportant to YouAs a member of the Partners HealthCareChoice ACO, you will have a team thatsupports you. You will have a PartnersHealthCare PCP to coordinate all of yourcare. You will have access to all PartnersHealthCare specialists and hospitals. Youmay also go to any hospital or specialistacross the state, as long as they are part ofthe MassHealth network. You will also haveaccess to special supports to help you stay12Your ID Card:You should have a MassHealth ID card withyour MassHealth ID number.The Partners HealthCare Choice ACO willalso send you an identification card (pleasesee example on next page).You should carry both your MassHealthcard and your Partners HealthCare ChoiceID card with you and show them when youget health care services or medicine. Pleasecheck your Partners HealthCare Choice IDcard to make sure the information iscorrect. If it’s not correct, if you did not geta card, or if you lose your card, please callPartners HealthCare Choice CustomerService at 1-800-231-2722.A MassHealth provider cannot refuse toprovide services to you if you do not haveyour ID cards. Your doctor or other providercan look for your name in the MassHealthsystem. If your provider cannot find your

information in the system, he or she shouldcall MassHealth.CARD FRONTYou can find MassHealth providers (such asmedical providers, medical specialists,behavioral health providers, and hospitals)across Massachusetts.Contact Information: For more information on theMassHealth provider network, or fora printed directory of MassHealthproviders, call the MassHealthCustomer Service Center at 1-800841-2900. More information on theMassHealth provider network canalso be found ctory/ For more information on the MBHPbehavioral health (mental healthand substance use disorder)providers, call MBHP at 1-800-4950086 or at their directory online atwww.masspartnership.com. For a printed directory of Partnersproviders, call the PartnersHealthCare Choice ACO customerservice center at 1-800-231-2722. You can fill prescriptions at allpharmacies in Massachusetts thatwork with MassHealth. CallMassHealth Customer Service at1-800-841-2900 to find the pharmacyclosest to you.CARD BACKYour Provider Network:In order to be a member of the PartnersHealthCare Choice ACO, your primary careprovider (PCP) must work at a PartnersHealthCare practice that is participating inthe ACO.Go to:www.massgeneralbrigham.org/MassHealthACOfor a list of primary care practices in thePartners HealthCare Choice ACO.The Partners HealthCare Choice ACO allowsaccess to the entire MassHealth network ofspecialists and hospitals for specialty care.If you have a medical or behavioral healthemergency, get care right away. Call 911 orgo to your nearest hospital emergencyFor questions or concerns, call the Partners HealthCare Choice ACO Customer Service Centerat 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:www.massgeneralbrigham.org/MassHealthACO13

room. If it’s a behavioral health emergency,you may also contact the EmergencyServices Program (ESP) in your area. Call thestatewide, toll-free ESP number at1-877-382-1609 to get the number for yourlocal ESP, 24 hours a day. ESPs providebehavioral health crisis assessment,intervention, and stabilization services.An emergency is any serious health careproblem that you think needs to be treatedright away. If you have an emergency, youshould get care immediately.Here are some common medical andbehavioral health (mental health andsubstance use disorder) emergencies, butthere are other kinds of emergencies, too.Medical emergencies: 14broken boneschest painconvulsionsfainting or dizzy spellsheart attacksheavy bleedingloss of consciousnesspoisoningserious accidentssevere burnssevere headachessevere painsevere woundsshortness of breathstroke (this includes numbness ordifficulty with speech)sudden change of vision sudden, severe pain or pressure inor below the chestthrowing up bloodthrowing up a lotsomeone who won’t wake upBehavioral health emergencies: wanting to harm yourselfhearing voiceswanting to harm other peopleOut-of-Network ServicesMedical servicesMassHealth will not pay for servicesdelivered by a provider who is not aMassHealth provider unless it is anemergency. You can get care foremergencies from any provider.Behavioral health servicesMBHP will not pay for services provided bya behavioral health provider who is not inthe network unless: it is an emergency; orthe MBHP network cannot providethose services.If MBHP’s network cannot provide theservices, MBHP will cover the out-ofnetwork services until the network canprovide them.Call MBHP if you have questions about outof-network behavioral health services.

Your MassHealth ACO Benefits:As a member of the Partners HealthCareChoice ACO, you will have access toadditional benefits, support programs, andservices:Team Care: Our primary care providersprovide care in Patient Centered MedicalHomes. Your provider is part of a team ofproviders focused on your physical andbehavioral health care needs and wellbeing. The team coordinates all of your careand makes sure that you and your familyare able to make decisions about your ownhealth. Patient Centered Medical Homesuse technology to keep goodcommunication between providers, and cansometimes offer services such as emailvisits or video visits that are easier forpatients to access. Our primary carepractices are able to offer our ACOmembers services that are coordinated andbetter integrated into other parts of thehealth care system. We will also ask ourACO members about their experiences intheir Patient Centered Medical Homes, sowe can make sure we are meeting yourneeds.Care Management: The PartnersHealthCare Integrated Care ManagementProgram is for members who have complexhealth care needs. As part of this program,some members are assigned to a team thatmay include a nurse, social worker,community health worker, and other teammembers. This team will work with themember’s primary care provider to makesure he or she is getting the care that he orshe needs. This program coordinates careacross the Partners HealthCare system,including specialty care doctors, hospitals,and home health care and also works withcommunity services and other supportservices. For patients that are especially sickor need extra support, we may try toconnect them with members of our teamcalled Community Health Workers.Community Health Workers help patients toset goals for their health and can help themnavigate the medical system, which can beconfusing at times. Sometimes, CommunityHealth Workers can even see patients intheir homes.Substance Use Disorder Services: Whenneeded, our ACO connects members with arecovery coach or a peer who hasexperienced substance use disordersfirsthand. Our ACO also works withmembers’ PCPs to improve access tosubstance use disorder treatment optionssuch as medication treatments, talk andgroup therapy, detox centers, andcommunity programs.Treatment of Behavioral Health conditionslike depression and anxiety: In our primarycare practices, we offer behavioral healthsupport specialists who can help guidepatients in their treatment with the help ofthe PCP, other social workers, andadditional members of the team.Smoking Cessation Support: Members haveaccess to support for quitting smoking,including access to medical support fromFor questions or concerns, call the Partners HealthCare Choice ACO Customer Service Centerat 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:www.massgeneralbrigham.org/MassHealthACO15

providers (including medication support).Many practices provide structured 8-weekprograms, support groups, and trainedcoaches.Diabetes Management and Education:Through practice and hospital-specificprograms and the Partners Virtual DiabetesCenter, members have access to medicalcare, educational materials, and coaching.They have access to educational groupclasses focused on maintaining a healthylifestyle, and can work with nutritionistsand diabetes educators. At some practices,members will also have access to fitnessand strength training classes and stressmanagement classes.W

The list is called the MassHealth Dental Provider Directory. You can view the directory yourself online at www.masshealth-dental.net. When You Travel: MassHealth will pay for you to see an out-of-state provider for medical care only if: you have an emergency; or your health would be at risk if you had to travel home. MassHealth .