MassHealth ACO Questions and Answers

Questions and Answers – From WellSense ACO Overview Training 03.15.23

Contact info for Jeanette Sanders: Jeanette.Sanders@wellsense.org

  • Are patients allowed to fill prescriptions at BIDMC? BIDMC pharmacies are in the retail network for non-specialty drugs.
  • Will there be paperwork for Credentialing? We have been working with the BILHPN Network Relations team and will reach out directly if additional credentialing information is needed.
  • We have a patient on Tufts Direct who states they have not received anything from MassHealth regarding the ACO, why would this be? For the April 1st MassHealth ACO Program implementation, communications were sent to patients whose primary care providers are part of the MassHealth ACO Program, MCO Program or PCC Plan that will be transitioning to one of these programs.
  • What’s going to happen with all our pediatric patients who get specialty and sub specialty care in Boston who are expressing concern that those connections will be lost? Boston Children’s Hospital specialty care is in-network for BILH ACO members.
  • Will patients have to stay within their ACO? Will they be able to obtain a referral authorization to see specialists outside their ACO, or will they have to transfer care to stay within network? No referral is necessary to see a participating specialist, members may seek services with ANY contracted specialist within the WellSense network. Services are not limited to their ACO. *** A service may require an authorization.Resources for prior authorization requirements can be found in the Provider Portal and on the WellSense public facing website in the prior authorization matrix. https://www.wellsense.org/hubfs/Provider/Prior%20Authorization/MA_Prior_Auth_Matrix.pdf

  • I have a patient who was switched from Allways, to Tufts together with BIDCO, and is now being transferred to Wellsense. All within 2 months – Is this a miscommunication within the product? The Tufts BIDCO to WellSense member transition/communication is due to the joining of the Lahey ACO and BIDCO ACO into one BILH ACO with WellSense beginning 4/1. Unfortunately, we don’t have insight into the transition from Allways to BIDCO.
  • We use Change Health for claims submissions. Will that work? Methods which have used historically for claims submission to WellSense (formerly BMC HealthNet) will not change.
  • Are the clearinghouses listed on the screen the only ones utilized to process electronic claims or are there others? Trizetto is an umbrella group for clearing houses.Methods which have been used historically for claims submission to WellSense will not change.
  • Is there a way to check if the patient needs authorization or referral for certain procedures in the provider portal? Resources for prior authorization requirements can be found in the Provider Portal and on the WellSense public facing website in the prior authorization matrix. https://www.wellsense.org/hubfs/Provider/Prior%20Authorization/MA_Prior_Auth_Matrix.pdf
  • Can you please cover the referral requirements to specialists? Referrals are not required for members to see in-network specialists. Some procedures may require prior authorization, and visits to out-of-network specialists require authorization.
  • Will we have access to policy numbers for these patients prior to the patient coming in for visits for authorization request, especially for continuing care i.e., rehab services? Yes, this information is already available in the WellSense provider portal for eligibility beginning 4/1/23. Eligibility can also be checked through EVS and NEHEN.
  • Can we still use Covermymeds for rx PAs? Yes, this tool can continue to be used.
  • If a providers panel is closed, will existing patients be allowed to choose them as a PCP? Will new patients be allowed to choose a PCP with a closed panel? Members can select a PCP with a closed panel if permission is given to WellSense by the practice.
  • Are patients no longer going to be able to have their prescriptions sent to Walgreens? Walgreens pharmacies are out of network for WellSense ACO members. Effective April 1st, new members will have 90 days to continue using their existing retail pharmacy, including Walgreens pharmacies. By July 1st, members must transition their prescriptions to a WellSense in-network retail pharmacy, which excludes some retail pharmacies in Massachusetts, including Walgreens pharmacies. More information can be found at the continuity of care page on the WellSense website here: https://www.wellsense.org/providers/ma/augmented-continuity-of-care-policy

  • We’ve tried to get registered for BMC website, is Jeanette who we reach out to? Yes, please reach out to Jeanette Sanders @ Jeanette.Sanders@wellsense.org with questions on the Patient Portal.