News from NEPHO – AUGUST 2023 Edition


Primary Care Providers

  • Erin Bursey, NP of Beth Israel Lahey Health Primary Care, Family Medicine Associates 195 School Street Manchester, MA 01944 Phone: 978-526-4311 Fax: 978-525-2342
  • Jennifer Akeley, NP of Beth Israel Lahey Health Primary Care, Family Medicine Associates 195 School Street Manchester, MA 01944 Phone: 978-526-4311 Fax: 978-525-2342


  • Jeffrey Lane, MD of Northeast Emergency Associates 85 Herrick Street Beverly, MA 01915 Phone: 978-922-3000 Fax: 978-921-7011
  • Joel Pakett, MD of Microsurgical Eye Consultants 31 Centennial Drive Peabody, MA 01960 Phone: 978-531-4400 Fax: 978-531-7106
  • Tanner Brown, MD of Gurley Eye Care Associates 195 School Street Suite B Manchester, MA 01944 Phone: 978-526-4800 Fax: 978-526-7179


  • Francis Cleary, MD of Lahey Cardiology, Beverly 75 Herrick Street Suite 206 Beverly, MA 01915 has retired effective 8/9/2023
  • Sherry Emery, MD of Beverly Pathology Associates 85 Herrick Street Beverly, MA 01915 will retire effective 10/1/2023


Office Manager Meeting
September 13, 2023 @ Noon
Speaker: Wendy Durham, Sound Moves Marketing
Topic: Medical Practice Marketing Strategies
Location: Teams Meeting

NP/PA Meeting
September 27, 2023 @ Noon
Speaker: Spencer Rabidou, PA – Lahey Institute of Urology, Beverly

Topic: Hematuria: Differential Diagnosis and Management Options
Location: Teams Meeting


Beverly Hospital has been rated high performing in three adult procedures and conditions by U.S. News & World Report in its 2023-2024 Best Hospitals.

“We are grateful for this recognition, which is only possible through the collective efforts of our team to deliver the highest standards of care,” said Tom Sands, President of Beverly Hospital.

U.S. News evaluated more than 4,500 hospitals across 15 specialties and 21 procedures and conditions.

Beverly Hospital was rated as high performing in three adult procedures and conditions: stroke, knee replacement and chronic obstructive pulmonary disease.

Learn more about the U.S. News and World Report’s best hospital rankings.


Texting Campaigns September 2023

There are two texting campaigns scheduled for September.


[Practice Name] @ Beth Israel Lahey Health:

Your health is important to us. Regular screening and preventive care, such as eye exams, labs, and monitoring blood pressure, are important to controlling diabetes. If you have not already done so, please call [PRACTICE NAME] to schedule a visit at [PRACTICE PHONE]. Reply STOP to cancel.

Colorectal Cancer:

[Practice Name] @ Beth Israel Lahey Health: Colorectal cancer screening can help find colon cancer early when it’s easier to treat. Most people over 45 years old should have a colon cancer screening. Please review this resource that lists your colon cancer screening options: If you are due for a screening, please discuss this at your next physical with your PCP. If you do not have a physical booked or need to update our records, please contact your PCP office at [PRACTICE PHONE]. To stop receiving messages, reply with STOP.

If you have any questions regarding the BILHPN texting campaigns please contact Laureen Viel at


Blue Cross Blue Shield

Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid and Artificial Pancreas Device Systems Prior Authorization Request Form #845

Please use this form to assist in identifying members who meet Blue Cross Blue Shield of Massachusetts’ (BCBSMA’s) medical necessity criteria for Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid and Artificial Pancreas Device Systems. To view the complete form, click here.

NICU Level of Care Authorization Program Delayed until Nov 1 

BCBSMA previously notified providers that BCBSMA would begin a partnership with ProgenyHealth to enhance the support of premature and medically complex infants and their families beginning on September 1. BCBSMA is moving the start date to November 1 to ensure that this program can be smoothly implemented. When the program begins on November 1, ProgenyHealth will manage the process for NICU level of care authorizations using InterQual criteria. It will apply to commercial (HMO, PPO, and Indemnity) members, and exclude our Medicare Advantage and Federal Employee Program members. For babies with approved NICU coverage, ProgenyHealth will provide care management during the NICU stay and for the first year of the baby’s life. To view the complete notification, click here.


Improving Postpartum Care

The Centers for Medicare & Medicaid Services (CMS) offers quality improvement (QI) technical assistance to help states increase access, quality, and equity of postpartum care in Medicaid and Children’s Health Insurance Program (CHIP). The technical assistance has two components:1) QI resources to help state Medicaid and CHIP staff and their QI partners begin improving postpartum care for their beneficiaries. 2) CMS’s Improving Postpartum Care learning collaborative, including approaches to improving postpartum care and state examples. For additional information, click here.

Access to Health Services through Telehealth Options

On July 31, MassHealth issued All Provider Bulletin 374 amending and reinstating the rules for services rendered via telehealth, effective October 1, 2023, for all MassHealth programs. Pursuant to this bulletin, MassHealth will continue to allow MassHealth-enrolled providers to deliver a broad range of MassHealth-covered services via telehealth and will reimburse for such services at parity with their in-person counterparts, including services provided through live-video, audio-only, or asynchronous visits. Additionally, MassHealth will allow an eligible distant-site provider delivering covered services via telehealth to bill a facility fee if such fee is allowed under the provider’s governing regulations or contracts. Finally, effective August 31, 2023, modifier V3, which was previously used to indicate services rendered via audio-only telehealth, will no longer be available. Providers must use modifier 93 in its place. Click here to view the bulletin. 


OTC COVID-19 Tests

Effective May 12, 2023, Implementation date August 14, 2023. The purpose of this Change Request (CR) is to implement an edit that will deny more than eight COVID-19 OTC tests billed in a calendar month for the same beneficiary. To view the transmittal, click here.

MLN Matters Number: MM13275: ESRD Prospective Payment System: October 2023 Update

Make sure the billings staff knows about changes, effective October 1, 2023: 1) Billing J0889 for daprodustat; 2) New ICD-10-CM codes for: a) Comorbidity payment adjustment; b) Acute kidney injury. For additional informaiton and to view the MLN Matters article, click here.

COVID-19: CPT Codes for Vaccines No Longer Authorized

The FDA announced more vaccines no longer authorized for use in the U.S. Medicare doesn’t pay for the following CPT codes effective: 1) June 1, 2023, Janssen: 0031A, 0034A, and 91303. 2) April 18, 2023, Moderna: 0011A, 0012A, 0013A, 0064A, 0091A, 0092A, 0093A, 0094A, 0111A, 0112A, 0113A, 91301, 91306, 91309, and 91311. 3) April 18, 2023, Pfizer: 0001A, 0002A, 0003A, 0004A, 0051A, 0052A, 0053A, 0054A, 0071A, 0072A, 0073A, 0074A, 0081A, 0082A, 0083A, 91300, 91305, 91307, and 91308. For additional information, click here.

Quarterly Update to the End-Stage Renal Disease Prospective Payment System (ESRD PPS)

The purpose of this Change Request (CR) is to (1) provide instructions for implementing the Transitional Drug Add-on Payment Adjustment (TDAPA) effective October 1, 2023 for a new Healthcare Common Procedure Coding System (HCPCS) code; (2) update the diagnosis codes eligible for the ESRD PPS comorbidity payment adjustment effective October 1, 2023 and add three diagnosis codes effective October 1, 2020; and (3) add two new diagnosis codes to the list of AKI diagnosis codes. For additional information, click here.

Influenza Vaccine Payment Allowances – Annual Update for 2023-2024 Season

Effective August 1, 2023, implementation date October 2, 2023. The purpose of this recurring update notification Change Request (CR) is to provide the availability of payment allowances for the seasonal influenza virus vaccines as updated on an annual basis, effective August 1 of each year. The recurring update applies to publication 100-04, chapter 17, section 20.5.9. To view the transmittal, click here.


Documentation Improvement for the Assessment and Plan

Assessment and Plan: The diagnosis should always be stated by the provider in the documentation with a status for the diagnosis, and also note if the diagnosis is acute or chronic and how the condition is being treated. Please indicate if current treatment is effective or needs changes. For additional information and to view the article, click here and scroll to related title.

Return to Referral Requirements

Fallon Health is returning to PCP referral requirements for specialty care. For Fallon Medicare PlusTM, Fallon Medicare Plus Central, and NaviCare this was effective July 1, 2023. For our MassHealth ACO plans—Berkshire Fallon Health Collaborative, Fallon 365 Care, and Fallon Health-Atrius Health Care Collaborative—the intention is to resume the PCP referral requirements for specialty care claims effective September 1, 2023. For additional information and to view the article, click here and scroll to related title.

Tufts Health Plan

Payment Policy Update: Preventive Services

The policy has been updated as follows: Added Language to Colorectal Cancer Screening Section “Cologuard (81528) is covered once every 3 years”. To view the complete policy, click here

Medical Necessity Guideline Update: Respite Care for Tufts Health Unify

The policy has been updated as follows: New MNG outlining criteria for respite care services, in alignment with the criteria from MassHealth’s “130 CMR 630.00: Home- and community-based services waiver services.” Prior authorization will be required for the codes H0045, T1005, S5150, and S5151. For additional information and to view the entire notification, click here.

Medical Necessity Guideline Update: Continuous Glucose Monitoring and Diabetes Management Devices for Tufts Health Together

The policy has been updated as follows: MNG name changed from Continuous Subcutaneous Insulin Delivery Devices for Tufts Health Together to Continuous Glucose Monitoring and Diabetes Management Devices for Tufts Health Together. In alignment with updates from MassHealth, criteria added for continuous glucose monitoring devices, effective August 1, 2023. For additional information and to view the entire notification, click here.

Behavioral Health and Substance Use Disorder Payment Policy Update

The policy has been updated as follows: Added MCI and CCS billing instructions for CBHCs, effective for DOS on or after June 22, 2023. To view the complete policy, click here.

Harvard Pilgrim Health Care and Tufts Health Plan (Point32Health)

Billing Medicare Members for Non-Covered Services

The Plan would like to provide some reminders regarding the steps a contracted provider must take prior to billing members of our Harvard Pilgrim Health Care and Tufts Health Plan Medicare Advantage plans/Senior Products for non-covered services. Members may come to their provider seeking a non-covered service, or providers as a provider may determine that it is appropriate to provide a service or treatment that isn’t normally covered by the member’s Medicare Advantage/ Senior Products plan. Please note that providers cannot directly bill the member for that service unless the member has been formally advised by the plan that the service will not be covered. In order to bill the member, providers must first request a plan review by submitting an organization determination request to the plan. If the plan makes a noncoverage determination and the member wants to proceed with treatment, providers must obtain the member’s informed written consent, which must include the specified non-covered service as well as the specific charge to the member. For additional information and to view the entire notification, click here.

Update on Authorization Requests for Home Care and Hospice

Tufts Health Plans wants to make providers aware of a change related to requests to extend an existing authorization for home care and hospice services for Harvard Pilgrim Health Care commercial members. Currently, if an extension request is approved, the authorization is updated with additional units and the end date is extended. Effective for dates of service beginning Oct. 1, 2023, providers must request a new authorization for services that extend beyond the end date of the existing authorization. Each approved authorization for the patient will have its own authorization number. For additional information and to view the entire notification, click here.


Chronic Kidney Disease (CKD) 

Defined by: 

  • Evidence of kidney damage (structural abnormalities seen on imaging, albuminuria, urinary sediment abnormalities, abnormal kidney biopsy, history of transplant) 


  • Decreased kidney function for 3 or more months 

Prevalence (Current estimates from the CDC) 

  • More than 1:7 US adults (~35.5 million) have CKD 
  • About 1:3 adults with severe CKD do not know they have CKD 
  • 34% of people over 65 years old have CKD 
  • 12% of people aged 45-54 years have CKD 

CKD Rates in adults based on Race/Ethnicity: 

  • Non-Hispanic White: 12% 
  • Hispanic: 14%  
  • Non-Hispanic Asian: 14% 
  • Non-Hispanic Black: 20% 

Risk Factors: 

  • Diabetes, hypertension, heart disease, auto-immune disease, urinary obstruction, drug toxicity, obesity, family history, older age, race etc. 




Please take a moment to share this newsletter with staff members to ensure they are being kept up-to-date with important information.

Please click here to take a moment to read the Provider Spotlights!

Virtual Networking videos from NEPHO providers can be found here.

Please click here to listen to Episode 3 of Healthcare 360, a podcast from Dr. Rob Fields, Chief Clinical Officer at BILH. Click here to be directed to the series.

If you would like to be featured on the PHO website, please reach out to Alycia Messelaar at or 978-236-1784.

Click here for the PDF version of the updated PHO Directory as of August 2023. For your convenience, click here for the separate Specialists Only PDF directory to refer to as needed.

Please share this directory with your office by printing or showing them how to visit us online for an easy to use directory search tool.

Note: Primary care providers (PCPs) in the BILH Performance Network no longer need to submit an administrative referral to refer Blue Cross Blue Shield of MA, Harvard Pilgrim Health Care, or Tufts Health Plan members to a specialist in the BILH Performance Network. Please reach out to Alycia Messelaar at regarding questions pertaining to providers within the BILHPN Network. 

As a reminder, it is important to use the NEPHO Physician Directory when referring to a specialty physician. 

Here are the key memos that have been sent out over the last month –

JUST in case you missed it!

  • Request for Consent to Merge – 9/8/23 Deadline
  • 2024 Cigna Care Designations (CCD) Letter
  • Monthly BILH Pharmacy Newsletters
  • Monthly BILHPN BMC WellSense MassHealth ACO Newsletter
  • Monthly Beth Israel Lahey Health Performance Network CDI Newsletter
  • WellSense BILHPN Performance Network ACO – Monthly PC Cap Payment Details Report Delivery Update
  • BILH Integrity and Compliance Training Requirement – 12/31/23 Deadline
  • Boston Children’s Hospital
    • BCHMedEd August Newsletter Upcoming Courses
    • BCH Fall 2023 Satellite Provider Schedules (Click here to view, download and print the Peabody Schedule) 
    • Pediatric Environmental Health Grands Rounds: September 2023 (Click here to view, download and print the flyer) 

Please reach out to for a specific communication that you are unable to find.


Benefits and Eligibility Verification

When members arrive at your office it is important to ask to see their current health plan member identification cards at each visit.

Doing so will help you:

  • Identify the member’s product
  • Obtain health plan contact information
  • Speed claims processing  
  • Verify referral and prior authorization requirements


Coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts and referral and prior authorization requirements may be available based upon plan product design.

It’s strongly recommended that practice staff ask to see the member’s ID card for current information and photo ID to guard against medical identity theft. 

If you have questions, please feel free to contact Ann Cabral, Referral Manager, at or 978-808-5379.


There is one training session still scheduled for 2023. Click on the link below to register.

Arcadia Acuity Training

November 7, 2023, from 12:05 – 1 p.m.


OPTUM NEWSLETTERAugust- Coagulation defects and other specified hematological disorders

Please click here to view the 2023 Optum webinar schedule.

Coding Chronic Kidney Disease

  • Coding chronic kidney disease (CKD) to the appropriate stage is very important and is often missed by our providers.   
  • As the GFR decreases, the problem list should be changed to reflect the patient’s status 

  • Clinovations/Smartform will prompt for suspected CKD stage based on GFR values 
  • Avoid: Chronic Kidney Disease N18.0. This code does not define the CKD stage and has no HCC value.

** The new CMS 2024 model increases HCC weights for CKD III-V to 0.13 – 0.8 ** 

Please reach out to Jessica Bryan at with questions or concerns regarding this clinical documentation tip or any other coding guidance.


Beth Israel Lahey Health Primary Care, Beverly – 30 Tozer Road

  • The office staff and Dr. Spencer Amesbury are respectful, professional and friendly. I feel well cared for.
  • I love Dr. Karenjeet Chahal, and am so happy with her. When my last doctor left I was worried that I wouldn’t like my new doctor as much. I was pleasantly surprised!
  • I feel very comfortable with Dr. Neeraj Mahajan who is a very caring physician.

Beth Israel Lahey Health Primary and Specialty Care, Beverly – 30 Tozer Road Suite 203

  • Always treated with respect from Dr. David Driscoll and staff. Appointments are on time.
  • Dr. Alyssa Handler asked appropriate questions, listened attentively, and provided options for improving my health.
  • Dr. Deborah Shih is always professional, personal, complete and good for my overall health and well-being!

Beth Israel Lahey Health Primary Care, Beverly – 100 Cummings Center

  • Both Dr. Pierre Ezzi and the nurse were thorough, respectful, patient, attentive and excellent.

Beth Israel Lahey Health Primary Care, Beverly – 900 Cummings Center 

  • Dr. Andrew Lenhardt is professional, congenial, helpful, caring, knowledgeable and efficient. Couldn’t ask for more!
  • I always have a great experience with Dr. Andrew Lenhardt and his staff.
  • Dr. Daniel McCullough – I find this practice to be wonderful. Courteous, attentive and trustworthy. I have recommended them to friends.

Beth Israel Lahey Health Primary Care, Danvers – 480 Maple Street Suite 204 

  • Dr. Kristina Jackson – Very respectful doctors and staff. Comfortable to discuss health concerns.
  • My first time to this Dr. Timothy Loughran and his office. I was very pleased!

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

  • Dr. Amy Esdale and her staff put me at ease, treated me with respect and are very knowledgeable and professional.
  • My visit with Dr. Kathryn Hollett was thorough and everyone was respectful and kind.

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

  • Dr. Victor Carabba and his staff are very knowledgeable and professional.
  • Dr. Victor Carabba is one of the best doctors I have ever had in my 65 years. He genuinely cares for his patients!
  • Dr. Karen Damico was professionally great and she was caring and thoughtful.

Beth Israel Lahey Health Primary Care, Hamilton – 15 Railroad Avenue

  • Dr. William Medwid and staff provide an outstanding service with compassion.

Beth Israel Lahey Health Primary Care, Manchester – 195 School Street

  • I felt very comfortable asking questions and sharing my life experiences with Dr. Jana Oettinger and I was able to get blood tests taken right then, and the phlebotomist is the BEST!
  • Dr. Matthew Plosker is a knowledgeable doctor and I trust him. I’m glad he is my PCP.

Blackburn Primary Care, Gloucester – 1 Blackburn Drive

  • My visits with Dr. Jay Isaac are always very fulfilling and I am treated with great dignity. This has always been my experience and I am very grateful for it!

Cape Ann Medical Center, Gloucester – 1 Blackburn Drive

  • Dr. James Maguire listened carefully to my concerns and offered helpful suggestions. He spent more time with me than I expected, and I am grateful for his attention.
  • I have had only good experiences at Dr. Shawn Pawson’s office. He is extremely nice, helpful and understanding. His staff is courteous and respectful.
  • Dr. Shawn Pawson – After many years I am especially grateful to everyone at C.A.M.C for their hard work, professionalism and compassion to our community.

Cape Ann Pediatricians, Gloucester – 298 Washington Street

  • Staff are all friendly. Dr. Jeffrey Stockman does a great job listening, explaining and addressing concerns. I feel we are in good hands.
  • We always appreciate the kind and compassionate care from Dr. Jeffrey Stockman. All of the staff are wonderful!

Danvers Family Doctors, Danvers – 140 Commonwealth Avenue

  • Everyone was excellent, happy, smiling and helpful. Dr. Subroto Bhattacharya could not have been nicer and more knowledgeable and better yet, personable. Everyone was great!

Essex County Primary Care, South Hamilton – 42 Asbury Street 

  • Dr. Nicholas Avgerinos and his staff are amazing!
  • Dr. Nicholas Avgerinos – First time in this office was very pleased when I left. I felt heard and everyone was pleasant and forth coming with answers to any questions.

Garden City Pediatrics, Beverly – 83 Herrick Street

  • We always appreciate Dr. Suzanne Graves‘ care and compassion.
  • We love Dr. Elizabeth Humphreys! She spends the time to talk to us and offers a lot of good advice for first time parents. She has been a great support to us.
  • I love how understanding Dr. Meghan Weir is and how well she listens to our concerns and questions. She understands how scary it is to be a new parent and always makes us feel comfortable and makes sure no question goes unanswered. Dr. Weir has been great!

Leonard Horowitz, M.D., Danvers – 7 Federal Street

  • I have been seeing Dr. Leonard Horowitz for over 20 years. He has always been very attentive, explains everything in a way that I can understand easily, truly seems to care about his patients, and everyone that works there has always been very friendly.

North Shore Pediatrics, Danvers – 480 Maple Street 

  • Dr. David Danis – I love this office. Everyone is wonderful and kind. Love all the nursing staff and admin stuff. No complaints!
  • Dr. Lance Goodman is amazing. He always explains full details of what the issue is and how we go forth on handling it. He always follows up a few days later to check on the patient. He cares and you can see. He’s the best!

Brian Orr Pediatrics, Gloucester – 1 Blackburn Drive

  • I always have nothing but great things to say about Dr. Brian Orr and the entire staff. Thanks for always being available, attentive and AWESOME!

Thomas Pearce, MD, Gloucester – 279 East Main Street

  • Dr. Thomas Pearce has been my doctor for over 30 years for a reason. He has always provided the best care possible with compassion!


Thank you again for the wonderful response to our July POD quiz. Congratulations to the following winners who were randomly chosen out of all the respondents who answered 80% of the questions correctly.

Physician category – Alyssa Handler, MD
Advanced Practitioner category – Sarah Curran, NP

Office Manager category – Cynthia Sonia


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

This month’s winners are:

Teamwork Award went to Lisa Lucido (middle photo) – her certificate read:

“For your dedication, professionalism and outstanding teamwork you are nominated for this Teamwork Award by your peers at Cape Ann Pediatrics”

Shown with L-R Kayla Teng, NP – Lisa Lucido – Dr. Jeffrey Stockman
Patient Experience had two winners:
Erin Leblanc at BILH Primary Care, Gloucester – Shown above with Dr. Victor Carabba
“Erin was so professional and kind and positive and reassuring!”
Frank Sacco also at BILH Primary Care, Gloucester – Shown with Dr. Karen Damico
“Frank went above the effort most people would have done for me. He did a great job!”

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. Please be sure to look for the new winners in next month’s issue!