Mass General

Brigham ACO

A Handbook for Our MassHealth

Accountable Care Organization Members
Mass General Brigham ACO

Member Handbook
Table of Contents
WELCOME .......................................................................................................................................................... 2

INTERPRETER SERVICES ..................................................................................................................................3

SECTION ONE: YOUR MASSHEALTH BENEFITS ........................................................................................ 5

YOUR MASSHEALTH BENEFITS ................................................................................................................................5

W HEN TO CALL MASSHEALTH ..................................................................................................................................5
CHANGING YOUR HEALTH PLAN OR ACO................................................................................................................6
W HEN TO CALL MASSACHUSETTS BEHAVIORAL HEALTH PARTNERSHIP (MBHP) .................................................7
ORAL HEALTH AND DENTAL SERVICES ....................................................................................................................7
W HEN YOU TRAVEL ..................................................................................................................................................8
MASSHEALTH COPAYMENTS ....................................................................................................................................8
IF YOU GET A BILL FOR SERVICES ...........................................................................................................................8
REFERRALS AND PRIOR AUTHORIZATIONS ..............................................................................................................8
REPORTING FRAUD .................................................................................................................................................10
ADVANCE DIRECTIVES ............................................................................................................................................11

SECTION TWO: YOUR MASS GENERAL BRIGHAM MASSHEALTH ACO ............................................. 12

YOUR MASSHEALTH ACO ......................................................................................................................................12

YOUR ID CARD........................................................................................................................................................12
YOUR PROVIDER NETWORK ...................................................................................................................................13
OUT-OF-NETWORK SERVICES ................................................................................................................................14
YOUR MASSHEALTH ACO BENEFITS .....................................................................................................................15
W HEN TO CALL YOUR ACO ...................................................................................................................................17
24/7 CLINICAL ADVICE AND SUPPORT LINE ...........................................................................................................17
CHANGING YOUR PCP ...........................................................................................................................................17

SECTION THREE: YOUR RIGHTS ................................................................................................................ 18

MASSHEALTH ACO MEMBER RIGHTS ...................................................................................................................18

ACO MEMBER GRIEVANCE PROCESS ...................................................................................................................20
MASSHEALTH BOARD OF HEARINGS APPEALS PROCESS .....................................................................................21
MBHP GRIEVANCE AND APPEALS PROCESSES ....................................................................................................22
REMOVAL FROM YOUR PCP’S CARE .....................................................................................................................26
NOTICE OF MASSHEALTH PRIVACY PRACTICES ....................................................................................................27
NONDISCRIMINATION AND ACCESSIBILITY ..............................................................................................................27
Welcome
Welcome to the Mass General Brigham MassHealth ACO!

This is the Mass General Brigham ACO Member Handbook for you and any other members of
your household who have joined Mass General Brigham Accountable Care Organization
(ACO). It explains important information about benefits and services. This handbook will help
you understand your benefits under MassHealth and your benefits as a member of the Mass
General Brigham MassHealth ACO.

Mass General Brigham ACO is an Accountable Care Organization (ACO). ACOs are groups of
doctors, hospitals and other health providers who work together to care for their patients. At
Mass General Brigham ACO, our goal is to make sure that you have access to the doctors and
caregivers that you need to improve your overall health.

Please read this handbook carefully for more information about what Mass General Brigham
ACO can do for your health, what your rights are as a member, and important contact
information.

Thank you for choosing the Mass General Brigham ACO.

2
Interpreter services
You have the right to a medical interpreter at no charge to you. Please let us know your primary
language, and we will have an interpreter available to assist you.
Contact our call center at 877-468-8717.

CALL 877-468-8717 TO REQUEST A TRANSLATION

For questions or concerns, call the Mass General Brigham ACO Customer Service Center 3
at 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:
www.massgeneralbrigham.org/MassHealthACO
Interpreter services (cont.)
You have the right to a medical interpreter at no charge to you. Please let us know your primary
language, and we will have an interpreter available to assist you.
Contact our call center at 877-468-8717.

CALL 877-468-8717 TO REQUEST A TRANSLATION

4
SECTION ONE: Your MassHealth Benefits

Topics in this section:

◊ Your MassHealth Benefits
◊ When to Call MassHealth
◊ Changing Your Health Plan or ACO • go to MassHealth’s website at
◊ When to Call Massachusetts www.mass.gov/masshealth or
Behavioral Health Partnership • call MassHealth Customer Service at
(MBHP) 1-800-841-2900 (TTY: 1-800-497-
◊ Oral Health and Dental Services 4648 for people with partial or total
◊ When You Travel hearing loss).
◊ MassHealth Copayments
◊ If You Get a Bill For Services
◊ Referrals and Prior Authorizations When to Call MassHealth:
◊ Reporting Fraud
◊ Advance Directives You can call MassHealth Customer Service
at 1-800-841-2900, Monday through Friday,
8:00 a.m. to 5:00 p.m. The call is free. TTY
Your MassHealth Benefits:
line is 1-800-497-4648 or visit the
Your MassHealth benefits include MassHealth website at:
emergency services, medical services, vision www.mass.gov/masshealth.
care services, behavioral health (mental
Call the MassHealth Customer Service
health and substance use disorder) services,
Center:
pharmacy services, and dental services.
Please note that you will receive your • if you have questions about
behavioral health services through the MassHealth;
Massachusetts Behavioral Health • if you have questions about your
Partnership (MBHP). MBHP is MassHealth’s coverage or benefits;
behavioral health services contractor. • if you have questions about your
MassHealth eligibility;
Please keep in mind that MassHealth • if you have questions about Early
services and benefits change from time to and Periodic Screening, Diagnosis
time. Check MassHealth regulations for and Treatment (EPSDT) services for
more information about services and children under 21;
benefits covered by MassHealth, or call • if you want to change your Health
MassHealth Customer Service to ask Plan or ACO;
questions: • if you want to change your primary
care provider (PCP) within the ACO.

For questions or concerns, call the Mass General Brigham ACO Customer Service Center 5
at 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:
www.massgeneralbrigham.org/MassHealthACO
 • if you move or change your phone insurance. MassHealth may help you
number; pay for the other insurance.
• if your employment status changes;
• if you’re pregnant;
• if you need help reading any If you receive benefits other than
material you get from MassHealth; MassHealth, it is important that you report
• if you want Spanish versions of
changes to those programs:
information you get from
MassHealth; or • If you get Transitional Assistance for
• if you want to speak with someone Dependent Children (TAFDC) or
who speaks Spanish or another Emergency Aid for Elderly, Disabled
language. or Children (EAEDC), call your local
Department of Transitional
Assistance (DTA) office at 1-800-
445-6604 (TTY: 1-888-448-7695).
It is very important that you keep
MassHealth up to date with certain
• If you get Supplemental Security
circumstances in your life:
Income (SSI) or Social Security
• It is important to tell MassHealth as Disability Income (SSDI), call your
soon as possible about a new nearest Social Security
address or phone number. If Administration (SSA) office at 1-800-
772-1213 (TTY: 1-800-325-0778).
MassHealth can’t reach you, you
may lose your MassHealth benefits.
• If you get assistance from the
• It is important to tell MassHealth as Massachusetts Commission for the
soon as possible about the birth of a Blind (MCB), call the MCB at 1-800-
baby and other family changes, or a 392-6450 (TDD: 1-800-392-6556).
change in your income. MassHealth
wants to be sure you are getting the
best coverage you can, based on Changing Your Health Plan or ACO:
your circumstances.
Most MassHealth members can only change
• It is important to tell MassHealth if health plans or ACOs at certain times during
you have other health insurance, the year. To find out about changing, call
like Medicare, veterans’ benefits, or the MassHealth Customer Service Center
health insurance through your job or and say, “I would like to change my health
a family member’s job, or if you plan or ACO.”
have an option to get other

6
The MassHealth Customer Service Center Oral Health and Dental Services:
can:
Services for Children (Members Younger
• give you information about other Than Age 21)
health plans in your area;
• change your health plan while you MassHealth pays for dental services,
are on the phone; and including screenings, fillings, sealants,
• tell you when you can start getting cleanings, fluoride application, and many
health care from your new health other treatments for children younger than
plan. the age of 21. Routine exams are visits to
the dentist for a dental checkup. Dental
For additional information about your
checkups are an important part of your
health plan options, go to
child’s overall health. The dentist will look
www.MassHealthChoices.com.
in your child’s mouth to see if your child’s
On this site, you may also complete a form
teeth and gums and the bones supporting
to change your health plan or ACO.
the teeth are healthy. At this time, the
dentist will see if your child needs other
When to Call Massachusetts dental services. Sometimes during the
Behavioral Health Partnership checkup, the dentist will clean your child’s
(MBHP): teeth and take x-rays.

You can call MBHP Customer Service at Your child should begin going to the dentist
1-800-495-0086 (TTY 1-877-509-6981), when you see his or her first tooth appear,
24 hours a day. and no later than 12 months old. Your
child’s PCP will do a dental screening at
Call MBHP:
each well-child checkup and may also apply
• if you have questions about your a fluoride varnish to your child’s teeth to
behavioral health (mental health prevent cavities. The PCP will remind you to
and substance use disorder) services take your child to a dentist for a full oral
or benefits; examination and cleaning. Everyone should
• if you want more information about see a dentist for this full examination every
how to get these services or find a six months. No referral is needed from your
provider; child’s PCP to see a dentist for these
• if you need help reading any services.
material you get from MBHP;
• if you want Spanish versions of
information you get from MBHP; or
• if you want to speak with someone
who speaks Spanish or another
language.

For questions or concerns, call the Mass General Brigham ACO Customer Service Center 7
at 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:
www.massgeneralbrigham.org/MassHealthACO
Services for Adults (Members Aged 21 and MassHealth Copayments:
Older)
For information about copayments, go to
MassHealth members aged 21 and older are www.massgeneralbrigham.org/MassHealth
eligible for dental services performed by a ACO
MassHealth dentist. Covered dental
Scroll down to the Resources for Members
services for adults include screenings,
section and click on the links to Covered
cleanings, fillings, extractions, dentures, and Services.
some oral surgeries.
If you have questions, please call Mass
General Brigham ACO at 1-800-231-2722,
Monday through Friday, 8:00 am – 5:00 pm.
How to Find a Dentist
Referrals and Prior Authorizations:
MassHealth will pay for covered dental
services only if they are provided by dental Some covered services may need a referral
providers enrolled in MassHealth. Dental or prior authorization (PA) or both.
customer service representatives can help
you find a MassHealth dental provider who Referrals
is taking new patients, and can even help
Many services require your primary care
you schedule an appointment. To speak
provider (PCP) to give you a referral.
with a dental customer service
representative, call Dental Customer Some services do not need a referral, such
Service at 1-800-207-5019. Dental customer as:
service representatives can give you a list of
dentists who are enrolled in MassHealth. • emergency services;
• behavioral health services;
The list is called the MassHealth Dental
• obstetric (pregnancy) services; and
Provider Directory. You can view the
• family planning services.
directory yourself online at
www.masshealth-dental.net.

If you are getting care within the Mass

General Brigham system, then you do not
When You Travel: need a referral. For a list of Mass General
Brigham hospitals and organizations, go to:
MassHealth will pay for you to see an out-
www.massgeneralbrigham.org/MassHealth
of-state provider for medical care only if:
ACO
• you have an emergency; or
• your health would be at risk if you
had to travel home.

8
Prior Authorizations a decision on your provider’s request within
the following time frames:
MassHealth or MBHP must approve certain
health care and pharmacy services before • Pharmacy (medicine): 24 hours
you get them. This is called prior • Non-emergency transportation: 7
authorization (PA). During the PA process, calendar days (or the number of
MassHealth or MBHP determines if the days needed to avoid serious risk to
requested service is medically necessary for the health or safety of the member)
you. If you want to know if you need a PA • Private-duty-nursing services: 14
for a service or medication, you can: calendar days
• Durable medical equipment: 15
• ask your PCP;
calendar days
• check the Covered Services List
on the website: • All other services: 21 calendar days
www.massgeneralbrigham.org/Mass
HealthACO; If MassHealth approves the PA request,
• call the MassHealth Customer Service they will send a letter to your provider so
Center for questions about health you can get the services or medication.
care services and medications;
You will also get a letter from MassHealth
• call MBHP for questions about
if they:
behavioral health services; or
• go to www.mass.gov/druglist to see • do not authorize any of the
a list of medications that require PA. requested services or medication;
Emergency Services do not require prior • approve only some of the requested
authorization. You can use any emergency services or medication; or
room or other setting to receive Emergency • do not approve the full amount,
Services. time period, or scope of the services
or medication requested.
If you disagree with a decision made about If MassHealth does not act on a request for
a request for PA, you can appeal the
PA within the time frames above, you can
decision. Read more about appeals later in
file an appeal with the Board of Hearings.
this Handbook.
Read more about appeals later in this
Handbook.
MassHealth Prior Authorizations MassHealth will not pay for a service that
needs PA if approval was not given.
When your PCP or another medical provider
thinks you need a service or medication All medical and surgical elective (non-
that needs PA, your provider will ask emergency) admissions to an acute hospital
MassHealth for PA. MassHealth must make must be approved by MassHealth. If you

For questions or concerns, call the Mass General Brigham ACO Customer Service Center 9
at 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:
www.massgeneralbrigham.org/MassHealthACO
plan to be hospitalized for an elective grievance if you don’t agree with MBHP’s
procedure, your doctor or nurse will submit reasons. Read more about filing a grievance
the necessary paperwork to make a request later in this Handbook. If MBHP approves
on your behalf. If MassHealth approves the the request, MBHP will pay for the service.
request, they will notify you and your
provider and you can get the requested
services. You will get a letter if MBHP:
If MassHealth does not approve the • does not authorize any of the
hospitalization, they will send you a letter requested services;
telling you so. You have the right to appeal • approves only some of the
the decision to the Board of Hearings. requested services; or
• does not approve the full amount,
time period, or scope of the services
MBHP Prior Authorizations requested.
You have the right to appeal the decision to
When your behavioral health provider
MBHP. Also, if MBHP does not act on the
thinks you need a service that needs PA,
request within the time frames above, you
your provider will ask MBHP for the PA.
can file an appeal with MBHP. Read more
MBHP must make a decision on your
about filing an MBHP internal appeal later
provider’s request within 14 calendar days
in this Handbook.
unless you, your provider, or MBHP asks for
more time. This can be for up to 14 extra MBHP will not pay for a service that needs
calendar days. MBHP can ask for more time PA if approval was not given.
only if it’s in your best interest and more
information is needed.

If your provider or MBHP thinks that taking Reporting Fraud:

14 days to decide the request will put your
If you believe that a health care provider,
health at risk, MBHP will make a decision
doctor, hospital, or member is misusing
within three working days. This time frame
MassHealth, then you can report the
may be extended by an additional 14
situation to the MassHealth Fraud Hotline
calendar days, if you, your provider, or
by calling 1-877-437-2830.
MBHP asks for more time. MBHP can ask
for more time only if it is in your best
interest and more information is needed.

Any time that MBHP asks for more time,

MBHP will send you a letter to let you know
the reasons. You have the right to file a
10
Advance Directives:

An advance directive is a statement that

you write or sign that indicates who you
choose to make health care decisions for
you, and which health care treatment you
do or do not want if you get sick or injured
and can’t talk or write.

There are two kinds of advance directives: a

health care proxy and a living will.

A health care proxy is your written

permission for a family member or friend to
make health care decisions for you in case
you cannot make them yourself. This
person is called your “agent” or “proxy.”

A living will lets you describe what kind of

care you want or do not want if you cannot
make health care decisions. For example,
you may not want to be kept alive using life
support. Your living will helps your health
care proxy make decisions for you. If you do
not have a health care proxy or if your
health care proxy is not available, the living
will can help your providers care for you.

If you choose to sign a health care proxy or

living will, you can change your mind at any
time and write and sign new ones.

You should talk to a health care provider to

learn more about advance directives. For
more information, you can also call
MassHealth Customer Service or MBHP.

For questions or concerns, call the Mass General Brigham ACO Customer Service Center 11
at 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:
www.massgeneralbrigham.org/MassHealthACO
SECTION TWO: Your Mass General Brigham MassHealth ACO

Topics in this section: and better understand your care. In some

◊ Your MassHealth ACO cases, you may also work with additional
◊ Your ID Card staff to coordinate your care whether it is
◊ Your Provider Network
medical care, behavioral health care, or
◊ Out-of-Network Services
◊ Your MassHealth ACO Benefits other care services related to your health.
◊ When to Call Your ACO
You can visit this link for more information:
◊ 24/7 Clinical Advice and Support Line
www.massgeneralbrigham.org/MassHealth
◊ Changing Your PCP
ACO

Your MassHealth ACO:

Your primary care provider (PCP) is part of a Your ID Card:

new program: Mass General Brigham ACO. You should have a MassHealth ID card with
Mass General Brigham ACO is a MassHealth your MassHealth ID number.
Accountable Care Organization (ACO).
ACOs are groups of doctors, hospitals, and The Mass General Brigham ACO will also
other health care providers who come send you an identification card (please see
together to provide coordinated, high- example on next page).
quality care to MassHealth members. This
You should carry both your MassHealth
new program will help your PCP provide
card and your Mass General Brigham ACO
you with more coordinated care. Your
ID card with you and show them when you
benefits, doctors, and other health care
get health care services or medicine. Please
providers will remain the same.
check your Mass General Brigham ACO ID
Why the Mass General Brigham ACO is card to make sure the information is
Important to You correct. If it’s not correct, if you did not get
a card, or if you lose your card, please call
As a member of the Mass General Brigham
Mass General Brigham ACO Customer
ACO, you will have a team that supports
Service at 1-800-231-2722.
you. You will have a Mass General Brigham
PCP to coordinate all of your care. You will A MassHealth provider cannot refuse to
have access to all Mass General Brigham provide services to you if you do not have
specialists and hospitals. You may also go to your ID cards. Your doctor or other provider
any hospital or specialist across the state, as can look for your name in the MassHealth
long as they are part of the MassHealth system. If your provider cannot find your
network. You will also have access to
special supports to help you stay healthy
12
information in the system, he or she should specialists and hospitals for specialty care.
call MassHealth. You can find MassHealth providers (such as
medical providers, medical specialists,
CARD FRONT
behavioral health providers, and hospitals)
across Massachusetts.

Contact Information:

• For more information on the

MassHealth provider network, or for
a printed directory of MassHealth
providers, call the MassHealth
Customer Service Center at 1-800-
841-2900. More information on the
MassHealth provider network can
CARD BACK
also be found at:
https://masshealth.ehs.state.ma.us/
providerdirectory/

• For more information on the MBHP

behavioral health (mental health
and substance use disorder)
providers, call MBHP at 1-800-495-
0086 or at their directory online at
www.masspartnership.com.
Your Provider Network:
• For a printed directory of Mass
In order to be a member of the Mass General Brigham providers, call the
General Brigham ACO, your primary care Mass General Brigham ACO customer
provider (PCP) must work at a Mass General service center at 1-800-231-2722.
Brigham practice that is participating in the
• You can fill prescriptions at all
ACO.
pharmacies in Massachusetts that
Go to: work with MassHealth. Call
www.massgeneralbrigham.org/MassHealthACO MassHealth Customer Service at
for a list of primary care practices in the 1-800-841-2900 to find the pharmacy
Mass General Brigham ACO. closest to you.

The Mass General Brigham ACO allows If you have a medical or behavioral health
access to the entire MassHealth network of emergency, get care right away. Call 911 or

For questions or concerns, call the Mass General Brigham ACO Customer Service Center 13
at 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:
www.massgeneralbrigham.org/MassHealthACO
go to your nearest hospital emergency • sudden, severe pain or pressure in
room. If it’s a behavioral health emergency, or below the chest
you may also contact the Emergency • throwing up blood
Services Program (ESP) in your area. Call the • throwing up a lot
statewide, toll-free ESP number at • someone who won’t wake up
1-877-382-1609 to get the number for your
local ESP, 24 hours a day. ESPs provide Behavioral health emergencies:
behavioral health crisis assessment,
• wanting to harm yourself
intervention, and stabilization services.
• hearing voices
An emergency is any serious health care • wanting to harm other people
problem that you think needs to be treated
right away. If you have an emergency, you
should get care immediately. Out-of-Network Services
Here are some common medical and Medical services
behavioral health (mental health and
substance use disorder) emergencies, but MassHealth will not pay for services
there are other kinds of emergencies, too. delivered by a provider who is not a
MassHealth provider unless it is an
Medical emergencies: emergency. You can get care for
• broken bones emergencies from any provider.
• chest pain Behavioral health services
• convulsions
• fainting or dizzy spells MBHP will not pay for services provided by
• heart attacks a behavioral health provider who is not in
• heavy bleeding the network unless:
• loss of consciousness • it is an emergency; or
• poisoning • the MBHP network cannot provide
• serious accidents those services.
• severe burns
If MBHP’s network cannot provide the
• severe headaches
services, MBHP will cover the out-of-
• severe pain
network services until the network can
• severe wounds
provide them.
• shortness of breath
• stroke (this includes numbness or Call MBHP if you have questions about out-
difficulty with speech) of-network behavioral health services.
• sudden change of vision

14
Your MassHealth ACO Benefits: she needs. This program coordinates care
across the Mass General Brigham system,
As a member of the Mass General Brigham including specialty care doctors, hospitals,
ACO, you will have access to additional and home health care and also works with
benefits, support programs, and services: community services and other support
Team Care: Our primary care providers services. For patients that are especially sick
provide care in Patient Centered Medical or need extra support, we may try to
Homes. Your provider is part of a team of connect them with members of our team
providers focused on your physical and called Community Health Workers.
behavioral health care needs and well- Community Health Workers help patients to
being. The team coordinates all of your care set goals for their health and can help them
and makes sure that you and your family navigate the medical system, which can be
are able to make decisions about your own confusing at times. Sometimes, Community
health. Patient Centered Medical Homes Health Workers can even see patients in
use technology to keep good their homes.
communication between providers, and can Substance Use Disorder Services: When
sometimes offer services such as email needed, our ACO connects members with a
visits or video visits that are easier for recovery coach or a peer who has
patients to access. Our primary care experienced substance use disorders
practices are able to offer our ACO firsthand. Our ACO also works with
members services that are coordinated and members’ PCPs to improve access to
better integrated into other parts of the substance use disorder treatment options
health care system. We will also ask our such as medication treatments, talk and
ACO members about their experiences in group therapy, detox centers, and
their Patient Centered Medical Homes, so community programs.
we can make sure we are meeting your
needs. Treatment of Behavioral Health conditions
like depression and anxiety: In our primary
Care Management: The Mass General care practices, we offer behavioral health
Brigham Integrated Care Management support specialists who can help guide
Program is for members who have complex patients in their treatment with the help of
health care needs. As part of this program, the PCP, other social workers, and
some members are assigned to a team that additional members of the team.
may include a nurse, social worker,
community health worker, and other team Smoking Cessation Support: Members have
members. This team will work with the access to support for quitting smoking,
member’s primary care provider to make including access to medical support from
sure he or she is getting the care that he or providers (including medication support).

For questions or concerns, call the Mass General Brigham ACO Customer Service Center 15
at 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:
www.massgeneralbrigham.org/MassHealthACO
Many practices provide structured 8-week Shared Decision Making Tools: Multimedia
programs, support groups, and trained decision aids may be provided to members
coaches. through the Patient Gateway or mail.
Decision Aids encourage interaction
Diabetes Management and Education:
between members and clinicians to engage
Through practice and hospital-specific
in decision making about members’ own
programs and the Mass General Brigham
conditions and to tailor treatment to their
Virtual Diabetes Center, members have
goals and concerns.
access to medical care, educational
materials, and coaching. They have access On-Line Patient Portal: Our web portal,
to educational group classes focused on Patient Gateway, offers a convenient,
maintaining a healthy lifestyle, and can efficient, and secure way for members to
work with nutritionists and diabetes access their health information, renew
educators. At some practices, members will prescriptions, request referral
also have access to fitness and strength authorizations and communicate with their
training classes and stress management health care team. Patient Gateway also
classes. offers members access to quality health and
wellness information and other
Weight Loss Support: Members have access
engagement tools supported by Mass
to a range of weight loss support programs,
General Brigham ACO. To sign up for Patient
including individual and group coaching,
Gateway, just ask about it in your PCPs
meal supplements, prescription
office or go to: https://patientgateway.org
medications where needed, nutrition
guidance, and lifestyle change support Certified Community Partner Program:
groups. Care management services are available for
some members who need help coordinating
Customized Educational Videos:
and connecting with community-based
Customized educational videos provide
mental health services, treatment for
answers to questions related to certain
substance use disorders, and long-term
health care topics, conditions, or diseases.
services and supports to help members
Mass General Brigham providers answer
remain independent in their homes. Some
these questions in videos on each topic.
examples of services like this are personal
These videos can be shared with members
care assistance and transportation.
before, during, or after a doctor’s visit.
Members who are interested in this
Educational Handouts: Providers have program should ask their primary care team
access to over 720 printable patient to access these services through state
education handouts in both English and certified community partners.
Spanish that offer “just in time” knowledge
to members during a doctor’s visit.

16
Care needs screening, other screenings, For questions related directly to your care,
and follow-up: When you first enroll in the appointments, or referrals, you should call
Mass General Brigham ACO, you will be your primary care office.
called by someone from the ACO team to
complete an initial assessment called a Care
24/7 Clinical Advice and Support Line:
Needs Screening. We will use this
information to help us customize your care The Mass General Brigham ACO has a
during your participation in the ACO. Thank clinical advice line at 1-833-372-5644 that
you for your willingness to complete this you can call twenty-four (24) hours a day,
survey. During visits to your PCP’s office, seven (7) days a week to get answers to any
you might also be asked to complete health-related questions you may have.
questionnaires about your mood, your use Every call is answered by a registered nurse
of cigarettes, alcohol, and drugs, and your who can respond to health-related
access to basic resources (like food and questions. When you call, the nurse will ask
shelter) that you need to stay healthy. you a few questions about your situation
These questions are all completely and details about your health concern to
confidential and will be used by your care help you decide if you should make an
team to help you receive the care you need. appointment with your provider, care for
An ACO thinks about ALL of your health yourself at home, or go to the Emergency
needs, even those that don’t require a Room.
doctor.

When to Call Your ACO: Changing Your PCP

You may call the Mass General Brigham You may change your PCP or your primary
ACO Customer Service Center at care practice location at any time, as long as
1-800-231-2722, Monday through Friday, you stay within your ACO. You may only
8:00 am – 5:00 pm. change your ACO at certain times of the
year. To change your primary care practice,
Call the ACO:
you may call the MassHealth Customer
• if you have questions about your Service Center at 1-800-841-2900 or go to
ACO and how it works www.MassHealthChoices.com.
• if you have questions about the
If you want to see a different provider at
benefits of being in the Mass
General Brigham ACO your primary care practice, you should talk
• if you need a new ID card with the practice directly.
• if you have questions about the
Mass General Brigham ACO provider
network

For questions or concerns, call the Mass General Brigham ACO Customer Service Center 17
at 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:
www.massgeneralbrigham.org/MassHealthACO
SECTION THREE: Your Rights
providers think should be done,
Topics in this section: regardless of cost or coverage.
◊ MassHealth ACO Member Rights
◊ ACO Member Grievance Process • The right to be part of decisions
◊ MassHealth Board of Hearings about your health care. You can
Appeals Process refuse treatment if you want to (as
◊ MBHP Grievance and Appeals
far as the law allows).
Processes
◊ Removal From Your PCP’s Care • The right to talk about your health
◊ Notice of MassHealth Privacy
care records with your providers,
Practices
◊ Nondiscrimination and and get copies of all your records.
Accessibility You can also ask for changes to the
records as the law allows.

• The right to choose your own PCP

MassHealth ACO Member Rights: and to change your PCP at any time.
You are able to leave your health
As a MassHealth ACO member, you have
plan at certain times of the year. To
certain rights. Your rights include the
change your primary care location or
following:
your health plan, call MassHealth
• The right to receive medically Customer Service.
necessary treatment.
• The right to get health care within
• The right to be treated with respect the time frames in the section of this
and dignity. handbook on referrals and prior
authorizations. If you do not get
• The right to privacy and behavioral health care when you
confidentiality. MassHealth and should, you can file an appeal with
your providers must keep your MBHP. If you do not get medical
health information and records care when you should, you can file a
private. They must not give other grievance with your ACO, as
people information about you unless described later in this handbook.
you give permission or the law says
they must. • The right to appeal to the Board of
Hearings and request a fair hearing
• The right to be told in advance—in a if you disagree with certain actions
manner you understand—about any or inactions by MassHealth or
treatments and alternatives that the MBHP.

18
• The right to a second opinion on a • The right to not be discriminated
medical procedure. against because of your race,
ethnicity, national origin, religion,
• The right to emergency care 24
sex, gender identity, age, sexual
hours a day, seven days a week in
orientation, medical or claims
any hospital or other setting that
history, mental or physical disability,
provides emergency services.
genetic information, or source of
• The right to receive information on payment.
available treatment options and
alternatives, presented in a manner • The right to have all the Mass
appropriate to your condition, General Brigham ACO’s options and
culture, functional status, language rules fully explained to you,
needs, required modes of including through use of a qualified
communication, and other interpreter or alternate
accessibility needs. communication mode if needed or
requested.
• The right to be free from any form
of restraint or seclusion used as a • The right to choose a plan and
means of coercion, discipline, provider that you qualify for at any
convenience, or retaliation, in time during your annual plan
accordance with applicable federal selection period, including
law. disenrolling from the Mass General
Brigham ACO and enrolling in
• The right to freely exercise your another MassHealth ACO, a
rights set forth in this Section and MassHealth MCO, or the
not have the exercise of those rights MassHealth PCC Plan.
adversely affect the manner in
which the Mass General Brigham • The right to receive timely
ACO treats you. information about changes to the
benefits or programs offered by the
• The right to be notified of these Mass General Brigham ACO at least
rights and considerations at least 30 days prior to the intended date of
annually, in a manner that you can the change.
understand, that takes into
consideration your culture, • The right to designate a
functional status, language needs, representative if you are unable to
and required modes of participate fully in treatment
communication. decisions. This includes the right to

For questions or concerns, call the Mass General Brigham ACO Customer Service Center 19
at 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:
www.massgeneralbrigham.org/MassHealthACO
 have translation services available to ACO Member Grievance Process:
make information appropriately
accessible to you or your If you ever have a problem with the care
you receive in the Mass General Brigham
representative.
ACO, you may file a grievance by telephone,
letter, fax or in person. The Mass General
• The right to receive a copy of and to Brigham ACO will let you know they have
approve your Care Plan, if any. received your grievance in writing, within 2
business days. The Mass General Brigham
• The right to expect timely, ACO will resolve and notify you of the
outcome of a grievance proceeding within
accessible, culturally and
30 calendar days from the date we received
linguistically competent, and the grievance.
evidence-based treatments.
Examples of problems you might file a
• The right to determine who is grievance about include the following:
involved in your care team, including • any action or inaction on the part of
the Mass General Brigham ACO;
family members, advocates, or other
• dissatisfaction with the quality of
providers of your choosing.
care or services provided;
• rudeness of a provider; or
• The right to experience care as • failure to respect your rights as
described in this Handbook, described in this Handbook.
including to receive a Care Needs
Screening and appropriate follow- To file a grievance by phone:
up. Call 1-866-455-1344

Grievances may also be faxed to:

• The right to have advance directives 617-526-1980
explained and to establish them.

• The right to file grievances as Grievances may be mailed to:

described in this Handbook, and the
Mass General Brigham
right to access MassHealth’s Appeals
Attn: ACO Grievance Counselor
processes. 399 Revolution Drive, Ste. 820
Somerville, MA 02145
• The right to be protected from
liability for payment of any fees that
are the obligation of the Mass As always, you can also contact MassHealth
directly 1-800-841-2900 (TTY: 1-800-497-
General Brigham ACO.
4648) for more information.

20
MassHealth Board of Hearings • holder of a power of attorney; or
Appeals Process: • health care proxy.

You can ask for an appeal with the

MassHealth Board of Hearings if you don’t How to File a Board of Hearings Appeal
agree with a decision that MassHealth or
You must file your Board of Hearings appeal
MBHP has made. This could include actions
in writing within 120 calendar days of the
or inactions by MassHealth about your
decision you want to appeal. To file an
medical and pharmacy benefits (for
appeal or to choose a representative for the
example, MassHealth refused to give PA for
purpose of your Board of Hearings appeal,
a service you think you should receive). For
you must fill out the Fair Hearing Request
questions about these appeals, call the
Form that comes with the notice about the
MassHealth Customer Service Center.
decision.
Appeals with the Board of Hearings are
You can ask for an expedited (fast) fair
called fair hearings. You have the right to
hearing if:
receive a fair hearing from an impartial
hearing officer of the Board of Hearings. • you are appealing a decision to deny
an acute hospital admission;
Appeals relating to MBHP must first go
• you are appealing MBHP’s decision
through MBHP’s internal appeals process,
on an expedited (fast) internal
described later in this Member Handbook. If appeal;
you still don’t agree with MBHP’s decision, • you are appealing a discharge or
you can ask for a fair hearing. transfer from a nursing facility.
You can name someone to represent you a If you want the Board of Hearings to handle
Board of Hearings appeal. Your your request as an expedited (fast) fair
representative should be someone who hearing, you must ask for the fair hearing
knows you (such as a family member or within 20 calendar days from the day that
friend) and knows about your problem. you got the decision you are appealing. If
Your representative could also be someone you file between 21 and 30 calendar days
who has the legal authority to act for you in after you got the decision, the Board of
making decisions related to health care or Hearings will not make the hearing faster.
payment for health care. For example, a
representative may be a:
Continuing Benefits During Your Fair
• guardian; Hearing at the Board of Hearings
• conservator;
If your fair hearing is about a decision to
• executor;
end, reduce, or stop a service that you get,
• administrator;
you may want to keep the service during

For questions or concerns, call the Mass General Brigham ACO Customer Service Center 21
at 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:
www.massgeneralbrigham.org/MassHealthACO
the fair hearing process. If you keep the behavioral health service is a mental health
service and lose the fair hearing, the cost of or substance use disorder service provided
the service may not be paid for. If you want by a mental health or substance use
to keep the service during the appeal, you disorder provider in MBHP’s provider
or your representative must send your fair network.
hearing request within 10 calendar days
You have the right to file a formal grievance
from the date of the letter from MassHealth
if:
that told you the service would change. If
you are appealing a decision by MBHP, you • you were not treated with respect
must file the appeal within 10 calendar days by MBHP staff or providers;
from the date of the letter telling you • your rights were not respected by
MBHP’s decision on your internal appeal. MBHP staff or providers;
You must also ask to keep your service • you are not happy with the service
during the appeal process. you or a family member received
from an MBHP provider;
• you are not happy with any other
After You File a Board of Hearings Appeal action or inaction by MBHP, except
if it had to do with authorizing
You or your representative may read your
treatment or getting an
case files to prepare for the Board of appointment. In this case, you can
Hearings appeal process. The Board of file an MBHP internal appeal;
Hearings does not have MBHP files, so you • you don’t agree with MBHP’s
must contact MBHP to get your files if you decision to extend the timelines for
are appealing a decision by MBHP. At the deciding your request for PA or for
hearing, you may represent yourself or deciding an internal appeal; or
come with an attorney or other • you don’t agree with MBHP’s
representative at your own expense. decision not to review your appeal
as an expedited (fast) internal
If you do not understand English or are appeal.
hearing or sight impaired, tell the Board of
It may be best to first talk to your provider
Hearings. They will get an interpreter or
assistive technology. about your concern. If you don’t want to
talk to your provider or don’t like your
provider’s answer, you have the right to file
MBHP Grievance and Appeals a grievance with MBHP.
Processes:

The appeals process for behavioral health

services is a little different than the process
for other health services and benefits. A

22
How to File a Behavioral Health Grievance The MBHP Internal Appeals Process

Call MBHP at 1-800-495-0086 if you want to You can file an internal appeal with MBHP if
file a behavioral health grievance. MBHP you don’t agree with one of these actions or
will also help you if you need an interpreter inactions by MBHP:
or TTY services (for people who are deaf,
• MBHP denied your request for a
hard of hearing, or speech disabled). You
service, approved less service than
can also write a letter to MBHP telling them
you asked for, or said that a service
about your grievance. Send it to this
you asked for is not covered;
address:

MBHP • MBHP reduced, suspended, or

Attn: Quality Management Specialist stopped a service MBHP had
1000 Washington Street, Suite 310 covered or approved for you in the
Boston, MA 02118-5002 past;

• MBHP did not decide your request

When you file a grievance with MBHP, you for Prior Authorization (PA) for a
can choose a representative. To choose a service within the time that we
representative, you must give MBHP a should have (see pages 9-10 for
signed and dated letter that tells MBHP the more information on PA); or
name of your representative and that this
person can act for you. MBHP will send you • you cannot get an appointment for
a letter to tell you that they received your behavioral health services within the
grievance. MBHP will review your grievance time that you should be able to.
and may call you or your provider to get
In most cases, you will get a letter from
more information.
MBHP about one of these actions.
MBHP will investigate and resolve your However, you may appeal even if you did
grievance within 30 days. MBHP will send not get a letter from MBHP.
you a letter when they decide. Before
If you get a letter from MBHP telling you
MBHP finishes the review, you or your
about any of the actions or inactions above,
representative can ask for more time (an
you or your representative must file your
extension) of up to 14 days. MBHP may also
appeal for treatment before you got
get a 14-day extension if it’s in your best
treatment, or, if you have finished your
interest and they need more information. If
treatment, then within 90 calendar days
MBHP gets more time, they will send you a
after you got the letter. If you did not get a
letter to tell you the reason.
letter from MBHP, you or your
representative can appeal within 90

For questions or concerns, call the Mass General Brigham ACO Customer Service Center 23
at 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:
www.massgeneralbrigham.org/MassHealthACO
calendar days after you learned about one within the time that they should have, you
of the above actions or inactions. will receive a letter from MBHP explaining
how to appeal this decision. If you are
You can file an appeal by telephone or in
appealing because you could not get an
writing. Call MBHP, or write them a letter to
appointment for behavioral health services
this address:
within time frames, send a letter to MBHP
Massachusetts Behavioral Health including the following information:
Partnership
Attn: Appeals Coordinator • the type of service you were trying
1000 Washington Street, Suite 310 to get;
Boston, MA 02118-5002 • the date you asked for the
appointment; and
MBHP will also help you if you need an • the date of the appointment you
interpreter or TTY services (for people who got.
are deaf, hard of hearing, or speech
MBHP will send you a letter telling you that
disabled). If you have an urgent behavioral
they got your appeal.
health need, you can ask to have your
appeal processed more quickly. This is
called an expedited appeal.
Continuing Benefits During Your MBHP
Please include: Internal Appeal

• your full name; If your internal appeal is about an MBHP

• the name of the service that you’re decision to change a service you get now by
appealing if your appeal involves a ending it, reducing it, or stopping it, you
decision by MBHP to: may want to keep the service while you are
- deny your request for a appealing. If you keep the service but lose
service; the appeal, your service may not be paid
- approve less service than you for. If you want to keep your services during
asked for;
the appeal, you or your representative must
- not cover a service; or
send your appeal request within 10
- reduce, suspend, or stop a
calendar days from the date of the letter
service MBHP had covered or
that told you the service would change.
approved for you in the past;
You must also ask to keep your service
• why you feel MBHP should change
the decision; and while you are appealing.
• if you would like to keep the service
during your appeal.
If you are appealing because MBHP did not
decide your request for PA for a service

24
After You File an MBHP Internal Appeal related to your health. If your provider isn’t
involved in the request, MBHP can decide if
You have the right to tell the facts and
they should do a fast review.
provide evidence (proof) about your appeal.
You can do that on the phone or in writing. If MBHP denies your request for a fast
These facts and proofs will be used in the review, they will tell you in writing of this
review of your appeal. decision. MBHP will process your appeal
within the 30-calendar-day time frame. You
You may look at your case file, health care
have the right to file a grievance if you don’t
records, and other documents and records
agree with this decision. If MBHP approves
related to the appeal. If you would like to
your request for a fast review, they will
review these documents, call your provider
review your appeal within three calendar
or MBHP at 1-800-495-0086 (TTY: 1-877-
days. MBHP will send you a letter telling
509-6981 if you are deaf, hard of hearing, or
you the decision on your appeal. If you
speech disabled).
don’t agree with MBHP’s decision on your
appeal, you can file a request for a fair
Getting a Decision on Your MBHP Internal hearing with the MassHealth Board of
Appeal Hearings.

If you do not file an expedited (fast) internal

appeal, MBHP will send you a written Extending MBHP Internal Appeal
decision within 30 calendar days. This could Timeframes
be up to five days longer if you, your
If more time is needed to resolve the
representative, or MBHP asks for more
appeal, you, your representative, or MBHP
time. For questions about behavioral health
can ask for an extra 14 calendar days. If the
(mental health and substance use disorder)
appeal is an expedited (fast) appeal, you,
services, call the MBHP. The call is free.
your representative, or MBHP can ask for an
extra 14 calendar days. MBHP can ask for
An Expedited (fast) MBHP Internal Appeal more time only if:

If you have an urgent behavioral health • the extension is in your best

need and you think a 30-calendar-day interest;
review is too long, you, your representative, • MBHP needs more information that
or your health care provider can ask MBHP may lead to approval of your
for an expedited appeal (fast review). In request; and
most cases, if your provider asks for a fast • MBHP expects to receive this
information within the extra time.
review, MBHP will approve the request.
MBHP will refuse the request by your
provider for a fast review only if it’s not

For questions or concerns, call the Mass General Brigham ACO Customer Service Center 25
at 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:
www.massgeneralbrigham.org/MassHealthACO
If MBHP asks for more time, they will send If MBHP dismisses your internal appeal,
you a letter. If you don’t agree, you or your they will send you a notice telling you. If
representative may file a grievance. you think that you filed an appeal within 90
calendar days and have proof, you or your
representative can disagree with MBHP’s
Approval of Your MBHP Internal Appeal
decision to dismiss your internal appeal.
You will get a “Notice of Appeal Resolution” You or your representative must send
that tells you that your appeal is approved. MBHP a letter asking for a review of this
Your provider can immediately give you the dismissal within 10 calendar days of the
service you asked for. notice telling you that your appeal was
dismissed. MBHP will review its decision
and notify you if it will continue with your
Denial of Your MBHP Internal Appeal
appeal. If MBHP does not resolve your
If MBHP denies your internal appeal, they internal appeal within the required time
will send you a notice telling you. If you do frames, you can file your appeal with the
not agree with the decision, you can file an Board of Hearings:
appeal directly with the Board of Hearings,
• if MBHP does not resolve your
described earlier. appeal within 30 calendar days (or
within five extra calendar days if
Dismissal of Your MBHP Internal Appeal there is an extension); or
• if MBHP does not resolve your
MBHP may dismiss your internal appeal if: expedited (fast) appeal within three
calendar days (or within 14 extra
• someone else files the appeal for calendar days if there was extra
you and MBHP does not get your time).
written permission for that person
to serve as your representative
before the time frame for resolving Removal from Your PCP’s Care:
your appeal ends; or
• you or your representative filed the A PCP may ask to have you removed from
appeal more than 90 calendar days his or her list of patients. The provider can
after the letter from MBHP telling make this request if you have a pattern of
you that you had a right to appeal noncompliant or disruptive behavior. If
(or more than 90 calendar days after MassHealth approves the PCP’s request,
you learned about MBHP’s actions MassHealth will send you a letter to tell you
or inactions if you did not get a that you need to choose a new doctor. You
letter). have the right to appeal this decision to the
Board of Hearings, per the instructions
above.
26
A PCP cannot ask to have you removed
from their list of patients for these reasons: Notice Informing Individuals About
Nondiscrimination and Accessibility
• your health condition has gotten Requirements and Nondiscrimination
much worse; Statement: Discrimination is Against the
• you use a lot of medical services; Law
• your mental capacity is reduced; or
• your behavior has caused problems The Mass General Brigham ACO complies
because you have special needs. with applicable Federal civil rights laws and
does not discriminate on the basis of race,
color, national origin, citizenship, alienage,
Notice of MassHealth Privacy religion, creed, sex, sexual orientation,
Practices: gender identity, age, or disability. The Mass
General Brigham ACO does not exclude
MassHealth has some information that
people or treat them differently because of
explains how they may use health
race, color, national origin, citizenship,
information about their members and give
alienage, religion, creed, sex, sexual
it to others. This is called their “Notice of
orientation, gender identity, age, or
Privacy Practices.” You can get a copy of
disability.
this “Notice of Privacy Practices” by writing
to the following address: The Mass General Brigham ACO provides
free aids and services to people with
MassHealth Customer Service Center disabilities to communicate effectively with
55 Summer Street, 8th Floor us, such as:
Boston, MA 02110
• Qualified sign language interpreters
• Written information in other formats
You can also get a copy of this notice by
(large print, audio, accessible
going to:
electronic formats, other formats)
http://www.mass.gov/eohhs/docs/masshea
lth/privacy/npp-brochure.pdf
The Mass General Brigham ACO provides
To find out about how MBHP uses
free language services to people whose
behavioral health information and shares it
primary language is not English, such as:
with others, you can call MBHP at 1-800-
495-0068, or get a copy of MBHP’s Notice • Qualified interpreters
of Privacy Practices by visiting MBHP’s • Information written in other
website at www.masspartnership.com. languages

Nondiscrimination and Accessibility:

For questions or concerns, call the Mass General Brigham ACO Customer Service Center 27
at 1-800-231-2722. Hours are 8:00AM-5:00PM, EST. Or visit our website:
www.massgeneralbrigham.org/MassHealthACO
If you need these services, please contact Other Contacts:
our Customer Service at 1-800-231-2722.
You can also file a civil rights complaint with
If you believe that the Mass General the U.S. Department of Health and Human
Brigham ACO has failed to provide these Services, Office for Civil Rights (OCR),
services or discriminated in another way on electronically through the Office for Civil
the basis of race, color, national origin, Rights Complaint Portal, available at
citizenship, alienage, religion, creed, sex, https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
sexual orientation, gender identity, age, or or by mail or phone at:
disability, you can file a grievance with:
Phone: 1-800-368-1019 or
(TDD) 800-537-7697
The Mass General Brigham ACO Civil Rights
Coordinator/Grievance Counselor
Phone: 1-866-455-1344 U.S. Department of Health and Human
Fax: 617-526-1980 Services
200 Independence Avenue, SW Room
Or mailed to: 509F, HHH Building
Mass General Brigham Washington, D.C. 20201
Attn: Mass General Brigham ACO Civil
Rights Coordinator/Grievance Counselor
399 Revolution Drive, Ste. 820 Or by contacting the OCR New England
Somerville, MA 02145 Regional Office at:

You can file a grievance in person, by mail, Phone: 800-368-1019, (TDD) 800-537-7697
or by fax. If you need help filing a grievance,
Office for Civil Rights U.S. Department of
our Civil Rights Coordinator/Grievance
Health and Human Services
Counselor is available to help you. Government Center J.F.Kennedy Federal
Building - Room 1875
Boston, MA 02203

Complaint forms are available at

http://www.hhs.gov/ocr/office/file/index.h
tml

28