News from NEPHO – JANUARY 2021 Edition


Stay tuned for next month


Stay tuned for next month




Please check the meeting calendar on our website to get the latest meeting status, notification of the Coding and Billing webinars,  Specialty Specific meetings, and POD/IPA meetings.


Date: Wednesday, February 10, 2021 @10:30 – 11:30 am
Risk Adjustment Coding Review
GoogleMeet Conference Call

Date: Wednesday, March 17, 2021 @10:30 – 11:30 am
Coding and Billing Annual Wellness Visits
GoogleMeet Conference Call

Date: Wednesday, March 31, 2021 @10:30 – 11:30 am
Evaluation and Management (E/M) Documentation Best Practice
GoogleMeet Conference Call

Date:  Thursday, February 18, 2021 @5:30 pm
GoogleMeet Conference Call
RSVP: or 978-236-1784

Date:  Wednesday, February 24, 2021 @12:00 pm
GoogleMeet Conference Call
RSVP: or 978-236-1784



Thursday, March 25 @12:30pm  │   WednesdayMarch 31 @7:00 am   │   Wednesday, April 7 @5:30 pm

Please note: the same presentation will be repeated at each of the three Open Meeting I sessions. Attendance at more than one Open Meeting I meeting will NOT provide additional attendance credit.

Primary Care Physicians and Specialty Physicians  will receive credit for March 2021 meetings by attending an Open I meeting session.

Open Meeting I in March/April 2021 will not replace March POD meetings. We will be having March pod meetings.

We will NOT have October Pod meetings as we will encourage everyone to participate in Open Meeting II.



  • Detail was shared on three new quality measures: HPV Vaccination, Risk of Continued Opioid Use, and Depression Screening and Follow Up plan.
  • A high level quality plan was shared for discussion and input by attendees.


  • Case based questions and discussion on Depression and Anxiety was facilitated and was well received by attendees.
  • An update on the Diabetes Care Collaborative Pilot continued roll out plan was shared.


  • A discussion on out of network referrals and patient education was facilitated by reviewing questions posed by a non-patient contact and the answers that were provided in response by Dr. Peppe.
  • Suggestions for potential language/patient education were shared for discussion.

INFORMATIONAL: 2021 Meeting Attendance Policy and MassHealth Formulary changes were shared.


Harvard Pilgrim Health Care

Harvard Pilgrim Health Care-Tufts Health Plan Combination Finalized

Harvard Pilgrim Health Care is pleased to share with providers that the combination of Harvard Pilgrim Health Care and Tufts Health Plan received all the necessary regulatory approvals and officially closed on January 1, 2021. While Harvard Pilgrim Health Care and Tufts Health Plan are officially one organization, the heritage brands and products will remain in the market for a period of time as the Plans transition technologies and processes. There are no immediate changes for our network providers — claims and reimbursement processes, policies, public websites and secure portals, vendors, and resources remain the same. The one exception is for Tufts Health Freedom Plan, which was sold to UnitedHealthcare in connection with this transaction. For additional information and to view the notification, click on the link below.

New Program Available to Members with Advanced Illness

Beginning February 1, 2021, Harvard Pilgrim Health Care is partnering with Aspire Health to offer a new palliative care program to commercial members who are facing an advanced illness. Aspire’s team of doctors, nurse practitioners, nurses, and social workers provide an extra layer of support for members. The program assists members with complex medical, behavioral, social and palliative needs, aiming to prevent unnecessary hospitalizations, provide relief from symptoms, and offer support with managing the stress of having a serious illness. To view the updates, click on the link below. Posted to the Network Matters, January 2021.

HEDIS 2021 Coming Soon: Provider Cooperation is Crucial

In the next few weeks, providers may receive a letter or a phone call from a Harvard Pilgrim representative requesting copies of medical records for specific patients related to the HEDIS project. The Plan appreciates provider’s assistance in providing access to these records or in sending copies of the requested documentation for review. Providers can be assured that the staff will maintain confidentiality of all medical information as required by HIPAA regulations. Provider’s help is crucial to the project, as every medical record counts, and prompt response will ensure that Harvard Pilgrim’s HEDIS measures accurately represent the high quality of care providers provide to members. To view the updates, click on the link below. Posted to the Network Matters, January 2021.

Blue Cross Blue Shield of Massachusetts

January 2021 Medical Policy Announcements

BCBSMA posted a list of policies which include the following: 1) New and revised policies; 2) Clarified policies; 3) Retired policies. A full draft version of each policy is available only by request, to ordering participating clinician providers, one month prior to the effective date of the policy. To request draft policies, contact Medical Policy Administration at To view the list, click on the link below.

Fallon Health

Revised Newborn Services Payment Policy

The Newborn Services Payment Policy has been revised. Updated Referral/notification/prior authorization requirements for MassHealth newborns, updated Billing/coding guidelines for MassHealth newborns, added requirement for birth weight on claims. For more information and to view the entire policy, click on the link below.

Revised Non-Covered Services Payment Policy

The Non-Covered Services Payment Policy has been revised. Added information relative to the CARES Act Provider Relief Fund; updated Notice of Financial Liability; added information about billing for no cost drugs and biologicals; added information about billing for no cost devices; updated code report (generated 09/02/2020). For more information and to view the entire policy, click on the link below.

Boston Medical Center Health Net Plan

Prior Authorization/Notification Requirements

Boston Medical Health Net Plan posted this following document, outlining common services that require prior authorization or Plan notification, is for use by participating BMC HealthNet Plan providers and vendors. Prior authorization/notification requirements apply to Plan products (MassHealth, Senior Care Options, and Qualified Health Plans/Commercial) as indicated by the symbol. To view the document, click on the link below.

Tufts Health Plans

2021 Senior Products Provider Manual

Tufts Health Plan has posted an updated 2021 Senior Products Provider Manual. To view the complete manual, click on the link below.

Harvard Pilgrim Health Care-Tufts Health Plan Combination Finalized


Please take a moment to look at our Provider Spotlight on the website by clicking here.

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

Interested in being Featured?

The Northeast PHO Provider Relations Department is excited to have you as part of our network of physicians!

In an effort to spread the word about the services you currently or will be providing, we would like to obtain information to be used to host virtual introductions, virtual drop-in sessions, a video to be posted on the NEPHO website, along with a provider spotlight bio to share with the NEPHO Primary Care Providers.  Click here to be directed to our Virtual Networking page.

Please send requested marketing materials to Alycia Messelaar,, in order to begin the marketing process.

Thank you,
The NEPHO Provider Relations Department

Please provide the following to create a 1-3 minute video about yourself.  This can be done right from your smartphone!  Please see Tips for Shooting better video on your smartphone.

Short bio (In paragraph format that includes the following information – please do not send a copy of your CV)

  • Name
  • Practice
  • Specialty
  • Ages treated
  • Education/Training
  • Past professional experience
  • Special interests
  • Whether you offer telehealth services
  • Personal hobbies
  • Professional photograph
  • Best hours and days to set up brief virtual meetings with PCP practices that are interested in speaking with you directly
  • Best ways to reach out directly regarding patient specific care questions

Please reach out to Alycia Messelaar at 978-236-1784 or to keep NEPHO informed of changes in practice schedules due to COVID-19 (office closures, limited office hours, scope of appointment, telehealth use, phone line to reach staff, etc.) or if you have questions about other practice schedules.

CLICK HERE to access a list of practices who are scheduling in office visits and/or TeleHealth visits at this time. 

Please take a moment to review your practice information and reach out to Alycia Messelaar, 978-236-1784 or with update requests.


The Northeast PHO is here to ensure you are not alone and that we are in this together. We are doing our best to keep your practice as updated as possible with all things COVID-19. Please take a moment to visit the COVID-19 tab by clicking here

Below you will find the most recent links to COVID-19 specific health plan materials and updates. Please note, we have included health plans that NEPHO does not contract with in an effort to help keep you well informed of current COVID-19 updates we have been made aware of. If you have questions or concerns, please reach out to Alycia Messelaar,


Please click here to view the BILHPN Pharmacy newsletter with valuable information regarding Evidence-Based Medicine in T2DM.  NEPHO will be participating in a BILHPN Collaborative initiative to reduce Total Medical Expenses (TME) based on appropriate utilization of SGLT2-i and GLP1 RA medications for patients with DM, HF and CKD.

For more information or questions, please contact Carol Freedman, NEPHO Pharmacy Manager at 978-380-4089 or


Referral Simplification- Tufts Medicare Preferred, Tufts Health Senior Care Options

There is a caveat to the Tufts Referral simplification process for some of the BILHPN Provider Units.

Tufts Medicare Preferred, Tufts Health Senior Care Options and Tufts Health Public Plan are excluded from Referral Simplification for legacy LCPN (Northeast PHO, WinPHO, Lahey) and MACIPA (Mt Auburn).

Referrals will be required for these patients once the Tufts Health Plan Referral Waivers and the Governor’s State of Emergency is lifted. Currently they are not required due to the waivers.

We will send out a notification to the practices once the waivers are lifted and referrals for these plans are required.

If you have any questions please feel free to contact Ann Cabral at or  978-236-1758.

NEPHO Top Doctors 2021

Each year, Boston Magazine partners with healthcare researcher Castle Connolly Medical Ltd. to create a definitive list of the best doctors in Boston, including hundreds of experts in fields such as dermatology, cardiology, orthopedics, pediatrics and more. Congratulations, and thank you to our 2021 Top Doctors! You make us proud!

Beth A. Bouthot
Beverly Hospital

Jeffrey Chang
Beverly Hospital

Jonathan S. Silver 
Cardiac Electrophysiology 
Lahey Cardiology, Beverly

Rita M. Sneeringer
Reproductive Endocrinology/Infertility
Cardone Reproductive Medicine and Infertility, LLC

Andre J. Witkin
Microsurgical Eye Consultants

To read the full list of Boston’s Magazine’s 2021 Top Doctors, please click here


Risk Adjustment Coding Overview

Hierarchical Condition Categories (HCC) are used to reimburse Medicare Advantage and Commercial plans based on the health status of their members. It pays for the predicted cost of patients by calculating payments based on demographic information and patient health status. A patient’s risk score is captured accurately by coding to their disease and conditions to the highest specificity. HCCs are diseases and conditions that are organized into body systems or similar disease processes. The top HCC categories include:

  • Major depressive and bipolar disorders
  • Asthma and pulmonary disease
  • Diabetes
  • Specified heart arrhythmias
  • Congestive Heart Failure
  • Breast and prostate cancer
  • Rheumatoid arthritis
  • Colorectal, breast, kidney cancer.

Risk Adjustment Coding a Joint Effort

Risk adjustment coding requires health plan management, provider group management, providers, practices, and coding professionals to work together to capture the health status of their patient membership. Each team member is critical for success of an organizations risk adjustment program. Health plan management and provider group management must provide leadership that supports the risk adjustment coding department to execute initiatives to improve health record documentation and risk adjustment coding. Providers must ensure their documentation complies with HCC reporting requirements and demonstrates that conditions are evaluated, monitored, assessed, and/or treated during face-to-face encounters (In-person and Telehealth). Risk adjustment coding professionals must follow best practice guidelines to ensure accurate coding and reporting of HCCs on an annual basis. By working together, the health plan and provider organizations can ensure compliance and meeting financial goals that better support HCC performance measures.

NEPHO has some very specific coding and documentation practices in place to help support provider HCC performance. The following examples provide guidance to practices that are working to improve risk adjustment coding capture:

Document and code all chronic conditions discussed and documented during a patient encounter: Chronic and/or permanent diagnoses should be documented as often as they are assessed or treated.

  • In-Person & Telehealth Example: Patient with diabetes II and CKD 3 stage 3a: Code E11.22, N18.31 – provider is also helping to manage recurrent depression and prescribing Zoloft every 3 months – Code: F33.8 (recurrent depression) – provider is helping to manage hypertension 2nd to diabetes – Code: I15.2

Clarify whether a diagnosis is current or “history of”: Anything that is listed as “repaired” or “resolved” should not be coded as current. Providers should be made aware of Z codes that are appropriate for these scenarios.

  • Example: Neoplasms that are current code to ICD-10 codes in Chapter 2: Neoplasms. Code: C61 (prostate cancer)
  • Example: Neoplasms that are no longer present should be coded to Chapter 18: History of Neoplasms. Code: Z85.46 (personal history of prostate cancer)

Update the patient’s problem list regularly: Make sure all problems listed as active are appropriate and haven’t been brought forward (copied and pasted) in error.

  • Example: Morbid Obesity with BMI > 40 Code: E66.01 BMI>40 Z68.41 – Patient lost 100 lbs updated Coding: E66.3 BMI >32 Z68.32

Providers should document conditions they monitor and treat: Diagnosis codes are not limited to what brought the patient to the office today. Any condition the provider monitors, evaluates, assesses, or treats should be included in the documentation.

  • Example: Patient has visit for fever and the provider also manages the patients hypertension – Code R50.8 (fever), I10 (hypertension)

Avoid using generic or unspecified codes: Code to the highest level of specificity. Use of generic or unspecified codes does not fully support medical necessity and the management of care for the patient. Payers need to have an accurate picture of the patient’s health status.

Example:  Congestive heart failure should be coded by type and acuity. The term congestive heart failure is considered nonspecific, outdated, and inadequate to fully describe the condition. Documentation should be present in the record of systolic and/or diastolic failure or dysfunction and acuity. Code: I50.31 (Acute diastolic congestive heart failure)

It is important to link manifestations and complications. Providers need to make the link between a manifestation and complication. Some terms that can be used to link conditions are “because of,” “related to,” “due to,” or “associated with.”

  • Example: Peripheral Vascular Disease “due to” diabetes – Code: E11.51
  • Example: Diabetes “associated with” Peripheral Vascular Disease – Code: E11.40

Please reach out to Shawn Bromley at or 978-236-1704 if you would like to learn more about the impact of risk adjustment coding capture and/or would like additional education with a provider or at the practice level.


Blackburn Primary Care, Gloucester – 1 Blackburn Drive

  • Dr. Jay Isaac and Beth Shanks, NP are consummate professionals. The staff are exceedingly courteous and diligent.

Lahey Primary Care, Beverly – 100 Cummings Center

  • Dr. Shahin was very attentive & explained my condition clearly.
  • Dr. Pierre Ezzi care provider and staff are always professional and courteous.

Lahey Primary Care, Danvers – 5 Federal Street

  • Dr. Margaret Legner is great. Liz is always helpful and a joy.

Lahey Primary Care, Danvers – 480 Maple Street

  • I have recommended  Dr. Kristina Jackson many times. She is excellent!

Lahey Primary Care, Hamilton – 15 Railroad Avenue

  • Family Medicine and  Dr. William Medwid are always CARING and PROFESSIONAL
  • Dr. Hugh Taylor always listens to me and asks me questions to learn more about my health concerns. He always provides treatments that resolve my health issues.

Lahey Primary Care, Manchester – 192 School Street

  • Dr. Jana Oettinger Took me a few years to find Dr. O. Glad I did!
  • Dr. Matthew Plosker is the most excellent physician I have ever met. Kudos to him!


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 winners are:
Kristina Delucia, Family Medicine Associates – Manchester, was recognized for going above and beyond to train her co-workers in EPIC referral order entry and collaborating with the PHO Referral team.
Deb Houde, Patton Park, was recognized for supporting quality improvement efforts.

Kristina Delucia and Gail Hendrickson, Office Manager
Family Medicine Associates, Manchester

Deb Houde, Office Manager and Dr. Michael Edwards

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 and in our website “Hot Topics” section.

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