NEWS FROM NEPHO – January 2020 Edition


New Providers will be listed after the
next Physician Orientation scheduled
for February 26, 2020 @7:30 a.m.



  • Jordan Glicksman, MD of North Shore ENT has resigned effective 11/15/2019
  • Eric Sterne, MD of Sports Medicine North has resigned effective 1/17/2020
  • George Lantz, MD of Pain Modulation Associates has resigned effective 12/31/2019
  • Harish Raja, MD of Microsurgical Eye Consultants has resigned effective 12/29/2019
  • Curtis Ersing, MD, Aimee Hromadka, MD, and Erin Heiskell, MD of Beacon Family Medicine will be resigning from the PHO effective 2/22/2020


OFFICE MANAGER MEETING     Click here for meeting flyer
Date: February 12, 2020 @ 12:00 p.m. (Noon)
Place: 500 Cummings Center, Suite 6500
Good Harbor Conference Room – Beverly, MA 01915
RSVP: Judith.O’ or 978-236-1739

Date: February 26, 2020 @7:30 a.m.
Place: 500 Cummings Center – Suite 6500
Good Harbor Conference Room – Beverly, MA 01915
RSVP: or 978-236-1784


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  • NEPHO worked with specialty practices on pharmacy savings and provided direct pharmacy consults to providers to better manage high cost patients.
  • NEPHO Referral Management team worked to help with system improvement projects:
    • Implemented Right Fax workflow to help improve patient scheduling with NEPHO specialists.
    • Worked with other risk units to build EPIC work queue logic to improve referral order routing.
  • NEPHO was awarded the HPHC Quality Grant funding to support a Telehealth Pilot Program. Telehealth services have been implemented into four NEPHO practices; Cape Ann Medical Center, Northeast Dermatology Associates, North Shore Neurology and EMG, and Danvers Family Doctors, PC.
  • NEPHO increased overall provider risk scores by focusing on coding initiatives supporting chronic condition capture.
  • NEPHO Provider Relations and the Contracting team helped to implement the new contract with AllWays Health Partners.
  • Please see the Quality section for more 2019 accomplishments.

We look forward to supporting our providers and practices as we move forward into 2020. There are a lot of exciting changes happening at a system level and the NEPHO team will continue to provide updates from the system.

Contact Shawn Bromley at or 978-236-1704 if you have questions regarding new initiatives and/or questions regarding Beth Israel Lahey Health Performance Network.


Planning for 2020

  • Joseph Peppe, MD invited discussion about planning for 2020.
    • Dr. Peppe reviewed the evolution of measurement and performance based metrics in healthcare.
    • Dr. Peppe proposed a pilot to help delineate PHO and practice roles using the diabetes population to start.
    • The goal of the diabetes care pilot is to improve patient care by creating clear maps of roles and responsibilities for the care of this population.
    • Dr. Peppe requested volunteers for the diabetes care pilot; three practices will be chosen to engage for the approximately 3 month pilot.

 Quality: 2020 Contract Quality Update

  •  Liz Isaac reviewed the AQC Gate score to date and the changes to the quality metrics for 2020 contracts.
    • While there are no changes to the measure slate, weights or thresholds, there are significant changes that will be challenging for 2020 performance.
    • The URI and Pharyngitis measures which were formerly limited to pediatric patients has expanded to include adult patients.
    • The Acute Bronchitis measure has expanded to include pediatric patients.
    • More detail and support related to these changes will be provided next month.
    • We have requested detail about our performance to date from LCPN, as the measure began July 1, 2019 and runs through June 30th.
  • The measure slate across BCBS, THP, HPHC, and AllWays was provided as a reference in the packet.  There is good alignment of measures across these payers.


Blue Cross Blue Shield of Massachusetts

BCBSMA will No Longer Accept Claim Adjustments Through Online Services 
Effective 01/18/2020 

Because corrections to claims are made using a replacement claim, as of January 18, 2020, BCBSMA will no longer accept claim adjustments when providers request them using the Adjustment Request link in Online Services (see image attached). Requests submitted using the Adjustment Request link will not be processed. BCBSMA will remove this link from Online Services at a future date. To view the complete notification, click here .

Harvard Pilgrim Health Care

Medicare Advantage: Diabetes Updates for March 1

  • Harvard Pilgrim is updating our StrideSM (HMO) Medicare Advantage Diabetes Management Devices Medical Policy, effective for dates of service beginning March 1, 2020.
    Updates are being made to coverage criteria for continuous glucose monitoring systems, insulin pumps, and sensor-augmented pump therapy, as well as for the replacement of diabetes management devices and for enhancements and accommodations for the visually and/or auditorily impaired.
    Additionally, the following CPT and HCPCS codes will be added to the policy and will require prior authorization:
  • 95250 – Ambulatory continuous glucose monitoring of interstitial
  • 95249 – Patient-provided equipment, sensor placement, hook-up, calibration of monitor, patient training and printout of recording
  • A9274 – External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories
  • E0784 – External ambulatory infusion pump, insulin [when specified as an open-loop automated insulin
  • K0553 – Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 Unit of Service
  • K0554 – Receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system
    The policy will also be updated to reflect that the Eversense Continuous Glucose Monitoring System and Omnipod Dash insulin pump are considered experimental/investigational and are not eligible for reimbursement.To request authorization, please complete the Durable Medical Equipment (DME) Medicare Advantage Prior Authorization Request Form and fax it to 866-874-0857 or call the Medicare Advantage Provider Service Center at 888-609-0692. For more information, please refer to the updated StrideSM (HMO) Medicare Advantage Diabetes Management Devices Medical Policy.

Submitting claims for members of certain HPI accounts

Effective Jan. 1, 2020, Boston Scientific and Kindred Healthcare members residing in Massachusetts, New Hampshire and Maine are being administered by Health Plans, Inc. (HPI) in a joint venture with UMR (United Healthcare’s third-party administrator solution). HPI is a Harvard Pilgrim company.  Please keep the following information in mind regarding the correct process for submitting claims for Fidelity Investments, Sedgwick Claims Management Services, Nielsen, Ocean State Job Lot, Boston Scientific and Kindred Healthcare members.

As a result of the HPI-UMR partnership, HPI manages claims from Massachusetts, New Hampshire and Maine providers for these members whereas UMR manages claims from Connecticut, Rhode Island, and Vermont providers for these members.

Recognizing members

You can recognize these members by their ID cards, which display the Harvard Pilgrim logo on the front of the card and the HPI logo on the back. In addition, the electronic eligibility response will display the plan name as Health Plans/UMR PPO National.

Please note that while HPI members typically are assigned member ID numbers beginning with HH, this is not the case for members of these accounts. For your reference, the group numbers for these accounts are as follows:

  •  Fidelity Group # 76-413512
  •  Group # 76-413554
  •  Sedgwick Group # 76-413489
  •  Ocean State Job Lot Group # 76-413926
  •  Boston Scientific Group # 76-414039
  •  Kindred Healthcare Group # 76-414055

Medicare Advantage: Chronic Care Improvement Program for Hypertension 
Effective 12/01/2019  

Harvard Pilgrim has developed a hypertension program to help support provider’s and their practice. along with Medicare Advantage patients diagnosed with hypertension. Attached are just a few ways Harvard Pilgrim supports members, and the clinicians treating them. For additional information, click here. Posted to Network Matters, December 2019.

Tufts Health Plans

Payment Policy Update: Opioid Replacement Therapy and Medication Assisted Treatment  
Effective 12/12/2019  

Tufts Health Plan has added billing instructions for Methadone Maintenance Programs; added benefit information for Tufts Health Direct per the Massachusetts Department of Insurance Bulletin 2019-07. To view the complete guideline, click here .

Massachusetts Health and Hospital Revised Prior Authorization Policy Update

January 9, 2020

Quick Summary

  • Following MHA and hospital feedback, MassHealth has drafted a revised prior authorization policy for medical diagnostic services, significantly reducing the number of services subject to it.
  • The policy is scheduled to begin in a transition phase on March 1, 2020, and will be fully implemented on June 1.
  • Training on the new policy will take place in February. Per MHA’s request, MassHealth will host an opportunity for provider engagement on the policy prior to making it final. A conference call is scheduled for Friday, January 17 at 9 a.m.

MassHealth Revises Prior Authorization Proposal

In late October, MassHealth proposed prior authorization requirements for more than 350 medical and diagnostic outpatient services. These services included obstetric and non-obstetric ultrasounds, advanced imaging, radiation therapy, polysomnography, cardiology procedures, and joint arthroscopy. MassHealth quickly retracted the policy following MHA concerns about the lack of provider input in developing it. MHA also objected to the inclusion of ultrasounds and radiation therapies, and communicated numerous other concerns and questions based on member feedback.

MassHealth shared the revised proposal (see above link) that significantly reduces the number of services subject to prior authorization from 371 to 168. Prior authorization is no longer required for most ultrasound services, radiation therapy, and arthroscopy – for at least the first year. MassHealth plans to revisit non-obstetric ultrasounds, radiation therapy, and arthroscopy a year from now and will include provider input in that decision making process. MassHealth does not plan on requiring prior authorization for obstetric ultrasounds in the future.

A transition phase of the policy will begin on March 1, 2020, when informational edits will be included on claims that do not have the required prior authorizations. Beginning June 1, 2020, claims will be denied for those that do not have the required prior authorization approvals.

The policy will apply to Primary Care Clinician, fee-for-service, and Primary Care ACO enrollees. (These enrollees all receive services that are paid for directly by the MassHealth agency as opposed to Medicaid Managed Care Organizations.) The policy does not apply to inpatient and emergency department services. It appears that MassHealth Limited and the Health Safety Net are not affected by the policy.

MassHealth reports that the expected turnaround time for non-urgent prior authorization requests will be two days, and will be up to four hours for urgent cases. A retroactive request will also be permitted for up to 14 days following the date of service.

For prior authorization requests that are denied, a peer-to-peer review process will be available prior to a member having to file a formal appeal through the MassHealth Board of Hearings.

MHA is pleased that MassHealth reconsidered its proposal and reduced the number of services that would require prior authorization. We remain concerned however with the overall approach as it contradicts the MassHealth ACO program philosophy of holding providers accountable through risk arrangements and quality performance measures, and is duplicative of ACO efforts to control utilization of members. Prior authorization contributes to unnecessary administrative complexity, clinician burnout, and delays in patient care. MHA also remains concerned with how the MassHealth vendor eviCore will efficiently and appropriately work with providers. For these reasons, MHA plans to continue to advocate on these issues with MassHealth and the other public policy makers.

MassHealth Provider Engagement

MassHealth will host a question-and-answer forum on Friday, January 17 from 9 to 10 a.m. The purpose is to solicit further feedback from providers before finalizing the policy. The call-in number is 866-692-3580, and the passcode is 643728050.

eviCore will host provider online training sessions during the month of February.

MHA expects additional details not outlined in the regulation to be communicated through these forums and in upcoming communications from MassHealth and eviCore.

For questions and comments on this policy, please contact MHA’s Dan McHale at or (781) 262-6044.

This MHA ADVISORY, along with other valuable healthcare information, is available to MHA member staff by visiting MHA’s website at

If you need a password to enter the site, please contact


2020 Fee Schedule Updates – BCBS, Medicare and

The 2020 Fee Schedules for BCBS, Medicare and Tufts HMO/PPO have been uploaded to the Northeast PHO website- please click here.  For detailed directions on how to download the fee schedules click here.

As a reminder, this portion of the website requires a login. In the event you have not been granted a NEPHO website username and password, please reach out to Alycia directly to request access, 978-236-1784.

Please contact Alycia Messelaar with questions or concerns or


Updated 2020 Northeast PHO Plan Participation and
Referral Requirement Grid

Please click here to access the updated 2020 Northeast PHO Plan Participation and Referral Requirement Grid. Please distribute this document to all individuals who would find this useful in their day to day operations.

By special request, we have begun to create individualized plan participation grids for practices who have product exclusions. Example: TMP exclusive contracted provider practices who do not accept any other Medicare Advantage HMO plans.

If you have questions about this document or are interested in an individualized plan participation grid, please feel free to reach out to Alycia directly at or 978-236-1784.


2019 Quality Highlights

As we begin a new year and a new Quality measurement period, the PHO Quality Team would like to recognize our practice colleagues for their hard work and accomplishments during 2019.  The ultimate goal of any quality program is to improve patient health and outcomes.  Here are some of the highlights from last year:

  • 1073 patients were screened for colorectal cancer.
  • 1371 patients received pap smears.
  • 1511 patients had mammograms.
  • 464   patients with diabetes had diabetic eye exams.
  • 756   patients with diabetes were compliant for nephropathy screening.
  • 1078 young women were screened for chlamydia.
  • 4660 adolescents had physical exams.

These numbers include patients in our commercial plans (Blue Cross HMO & PPO, HPHC & Tufts Health Plan).  This is only a small sampling of the great work you do every day.  Thank you for collaborating with the PHO Quality Team over the past 12 months.

Happy New Year!


Newer Diabetes Therapeutic Drug Classes and Insulins Chart

Newer agents for treatment of diabetes released over the past few years are listed on the Newer Diabetes Therapeutic Drug Classes and Insulin chart by medication class including common dosing, general health plan coverage and AWP cost. Types of insulin and costs are also available.

NEPHO Pharmacy Resources –

The Newer Diabetes Therapeutic Drug Classes and Insulin chart can now be located on the website in 3 different locations on the website. All pharmacy resources can be accessed via Quick Links, under the News and Resources tab and in the Clinical Services tab under Pharmacy Services.

New Generic Medications

See the list of First Time Generics scheduled to be released in the upcoming year and beyond.

For more pharmacy information, please see the BILHPN Pharmacy Program Newsletter 

For questions or more information contact Carol Freedman, NEPHO Pharmacy Manager at or  978 236 1774.


Population Health Focus

January is Cervical Health Awareness Month

Cervical cancer was once one of the most common causes of cancer death for American women. Despite the availability of good screening tests, the American Cancer Society’s estimates for cervical cancer in the United States for 2020 are:

  • About 13,800 new cases of invasive cervical cancer will be diagnosed.
  • About 4,290 women will die from cervical cancer.

HPV is the virus which causes cervical cancers.  Most women with HPV will not develop cervical cancer.  However, it is very important to have regular Papanicolaou “Pap” smear and/or Human Papilloma Virus (HPV) screening tests which allow for earlier diagnosis and treatment of cervical cancer.

Thanks to regular screening with Pap Smears and/or HPV testing, cervical pre-cancers are diagnosed far more often than invasive cervical cancer.

Cervical Cancer Screening Measure Update:

The Measure:

The percentage of women age 21 through 64 who were continuously enrolled during the quality Measurement Period and the two years prior to the Quality Measurement Period, excluding women who have had a hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix, who were screened for cervical cancer using either of the following criteria:

  • Women age 21-64 who had Pap performed every 3 years
  • Women ages 30-64 who had cervical high-risk human papillomavirus (hrHPV) testing performed every years
  • Women age 30-64 who had Pap/HPV co-testing performed every 5 years

General information: 

Code/Associated Diagnoses (ICD10):  Cervical Cancer screening Z12.4


OPTUM Newsletter – January 2020 Focus: Major Depressive Disorder

Transitional Care Management Coding and Billing Update

Transitional care management (TCM) includes services provided to a patient with medical and/or psychosocial problems requiring moderate or high-complexity medical decision making. TCM services involve a transition of care from one of the following hospital settings:

  • Inpatient acute care hospital
  • Inpatient psychiatric hospital
  • Long-term care hospital
  • Skilled nursing facility
  • Inpatient rehabilitation facility
  • Hospital outpatient observation or partial hospitalization
  • Partial hospitalization at a community mental health center

The transition necessitates management services, and there is an ascertained level of risk due to the nature of the patient’s condition. The responsibility for patient care rests with the healthcare professional overseeing transitional care services and the medical facility must be able to demonstrate that the patient’s psychosocial or medical issues necessitate intervention.

There are 2 CPT codes that may be used to report TCM:

99495: The patient requires “moderate medical decision complexity” within 14 calendar days of discharge

99496: The patient requires “high medical decision complexity” within 7 calendar days of discharge

In addition, all TCM services must meet required criteria in order to be deemed successful and thus qualify for reimbursement. Criteria includes:

  1. Interaction within two days of discharge, with exceptions set for those situations wherein the assigned case manager or medical professional is unable to reach the patient
  2. Non face-to-face services, typically things like review of tests and procedures, provision of educational materials, and assistance with appointment scheduling and community resources assignment.
  3. A face-to-face visit that must occur within either 14 days (moderate complexity cases) or 7 days (high complexity cases). Click here for the MLN Fact Sheet.

Reimbursement is greater than routine E/M visits and helps to reduce readmission cost:

Please contact Shawn Bromley at 978-236-1704 or for more information regarding TCM coding and billing requirements.

Online digital evaluation and management (E/M) services

In the 2020 CPT book, CMS is deleting code 99444, which was defined as an online E/M service by a physician or other qualified health care professional. CPT is adding three new time-based codes for online evaluation and treatment, for use by clinicians who have E/M in their scope of practice:

  • 99421  For an established patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes
  • 99422  11—20 minutes
  • 99423  21 or more minutes

Report these services once during a 7-day period, for the cumulative time according to CPT. These codes are for use when E/M services are performed, type that would be done face-to-face, are performed through a HIPAA compliant secure platform. These are for patient-initiated communications, and may be billed by clinicians who may independently bill an E/M service. They may not be used for work done by clinical staff or for clinicians who do not have E/M services in their scope of practice.

Other requirements:

  • The interaction must be documented in the permanent record.
  • If within seven days of the initiation of the online service a face-to-face E/M service occurs, then the time of the online service or decision-making complexity may be used to select the E/M service, but this service may not be billed.
  • If the patient initiates this online service within seven days after an E/M service for the same problem, these codes may not be billed.
  • If the patient inquiry is within seven days of an E/M service for a new problem, the online service may be reported.
  • This is for established patients, per CPT®.
  • This may not be billed by surgeons during the global period.
  • The digital service must be provided via a HIPAA compliant platform, such as an electronic health record portal, secure email or other digital applications.


Patient Experience Survey

MHQP will be conducting their annual patient experience survey again in April.  Adult primary care patients as well as pediatric primary care patients will be surveyed thru July so please be aware and help support this initiative.  This year, with the help of the Consumer Health Council (CHC), MHQP has created a new section on their website dedicated to supporting patients who wish to become more actively involved in their care and more engaged consumers of healthcare services.  This resource is now live at:

Cape Ann Medical Center – 1 Blackburn Drive

  • Dr. Janet Doran is superior. She quickly diagnosis and advises with total accuracy. Staff is always helpful and pleasant!
  • I think the world of Dr. Shawn Pawson!

Danvers Family Doctors, PC – 140 Commonwealth Avenue

  • I’ve had Danvers Family Doctors and  Dr. Subroto Bhattacharya for 18 years and the practice has
    improved my health immensely.  My experience with them is most beneficial.

Garden City Pediatrics – 83 Herrick Street

  • We love Dr. Suzanne Graves and the entire staff!
  •  Dr. Eric Sleeper provides great care and service for new patients!

 Lahey Health Primary Care, Beverly – 30 Tozer Road

  • I’ve always had a good positive experience with  Dr. Tina Waugh. She listens!
  • I feel fortunate to have Dr. Gail Ellis as my primary care physician.

Lahey Health Primary Care, Beverly  – 900 Cummings Center

  • Dr. Daniel McCullough is very supportive and accommodating – very positive work environment.

Lahey Health Primary Care, Beverly – 100 Cummings Center

  •  Dr. Pierre Ezzi has been my PCP for over 2 decades. His care has been EXCEPTIONAL!

Lahey Health Primary Care, Danvers – 5 Federal Street

  •  Dr. Margaret Legner is very attentive and thorough. I like and respect her.
  •  Dr. Mauri Cohen and his team are kind and caring every time I go there or call there.

Lahey Health Primary Care, Gloucester – 298 Washington Street 4th Floor

  •  Dr. Victor Carabba is on his game. I’ve never had a complaint about him. He’s awesome!

Lahey Health Primary Care, Gloucester – 298 Washington Street 1st Floor

  • I am very pleased with the care and treatment provided by  Dr. Amy Esdale and all of the staff in the

Lahey Health Primary Care, Manchester – 192 School Street

  • Excellent care!   Dr. Nicholas Avgerinos always listens and knows and shows all about health issues.
  •  Dr. Jana Oettinger – is the bomb!

North Shore Pediatrics – 480 Maple Street

  • We love Dr. David Danis and the whole office.
  • We are so happy with this practice and LOVE Dr. Lance Goodman!

Brian Orr, Pediatrics – 1 Blackburn Drive

  • We love  Dr. Brian Orr and his staff!


The Northeast PHO recognizes colleagues who provide a positive experience for our patients, help us keep care local and meet our quality targets.

This month’s winner is:

Anne Nuccio, Lahey Health Primary Care, Danvers, was recognized for collaborating with the practice providers to support improvement in the quality measures.

Please let us know if you would like to nominate a team member in your practice or another practice for the recognition program.

We will deliver gift cards to the winners each month, and they will be announced here in the newsletter.

Look for the new winners in next month’s issue!

Anne Nuccio and Dr. Mauri Cohen