News from NEPHO – JANUARY 2023 Edition


Check back next month for new providers.


  • Laurence Gordon, MD of Beth Israel Lahey Health Hamilton, 15 Railroad Ave South Hamilton, MA 01982 has termed effective 3/3/2023
  • Barry Burrows, MD of Essex County OB/GYN, 83 Herrick Street Suite 2004 Beverly, MA 01915 has retired effective 12/31/2022
  • Michelle Liang, MD of MicroSurgical Eye Consultants, 31 Centennial Drive Peabody, MA 01960 has termed effective 1/1/2023
  • Zaven Jouhourian, MD of Beverly Hospital Leland Unit, 85 Herrick Street Beverly, MA 01915 has retired effective 12/14/2022
  • Thomas Seman, MD of North Shore Pediatrics, 480 Maple Street Suite 3A Danvers, MA 01923 will be retiring effective 4/1/2023


Rheumatology Myths and Pearls with Dr. Bhavna Ferm – CME Credit
Date: Wednesday, February 8th, 6pm
Location: Teams Meeting
Click here to view the flyer
Click here to join the meeting

NP/PA Meeting
Date: Wednesday, February 22nd, Noon
Location: Teams Meeting

Office Manager Meeting
Date: Wednesday, March 8th, Noon
Speaker: Christine Ouellette
Topic: WellSense ACO
Location: Teams Meeting


Tuesday, March 7, 2023 @12:30pm

WednesdayMarch 22, 2023 @5:30pm

Thursday, March 30, 2023 @7:00am

  • These meetings will be virtual using Zoom. Emails with the Zoom links and meeting details were sent by Lisa Driscoll on 1/20/2023 and 1/23/2023. If you have any questions about the Open Meeting I sessions, please contact Lisa Driscoll at or 978-236-1744.
  • Please note: the same presentation will be repeated at each of the three Open Meeting I sessions.
  • Open Meeting I will take the place of the March POD meeting.


Congratulations to our NEPHO Physicians who were Recognized in Boston Magazine’s 2023 ‘Top Doctors’

Beth A Bouthot, MD – Nephrology

  • Beverly Hospital & AGH Nephrology 85 Herrick Street Beverly, MA 01915 and 298 Washington Street Gloucester, MA 01930 phone: 978-816-3515

Daihung Vu Do, MD – Dermatology

  • Massachusetts Dermatology Associates, P.C. 900 Cummings Center, Suite 311 T Beverly, 01915 phone: 978-225-3376

Mark P Hatton, MD – Ophthalmology

  • North Suburban Eye Associates, P.C. 669 Main Street, Wakefield, MA 01880 phone: 781-245-5200

Katherine S Masterpol, MD – Dermatology

  • DermPhysicians of New England, 83 Herrick Street Beverly, MA 01915 phone: 781-272-7022

Rita M Sneeringer, MD – Reproductive Endocrinology/Infertility

  • Cardone Reproductive Medicine and Infertility, LLC 2 Main Street Suite 150 Stoneham, MA 02180 phone: 781-438-9600

Benjamin A Solky, MD – Dermatology

  • Robert O’Brien Jr., MD & Associates, P.C. 140 Commonwealth Avenue Suite 201 Danvers, MA 01923 phone: 978-774-4100

Andre J Witkin, MD – Ophthalmology

  • Microsurgical Eye Consultants 31 Centennial Drive Peabody, MA 01960 phone: 978-531-4400


Below is a list of dates for BILHPN Acuity Training for Epic users and a link to the recording of the September 12, 2022 Session. Click on each date to register.

Provider Acuity Training Series with CME Credit

Click here to request access to view the Recording for the September 12th Provider Acuity Training Series Session.

March 7, 2023, from 5:30 – 6:30 p.m.

May 2, 2023, from 12 – 1 p.m. 

July 18, 2023, from 5:30 – 6:30 p.m. 

Arcadia Acuity Trainings

February 8, 2023, from 12:05 – 1 p.m.

May 10, 2023, from 12:05 – 1 p.m. 

August 10, 2023, from 12:05 – 1 p.m. 

November 7, 2023, from 12:05 – 1 p.m.


Blue Cross Blue Shield of Massachusetts

Updated Payment Policies Now Available

The attached payment policies, updated in Q4 2022, are now available on Provider Central. To view the complete notification, click here.

Authorization Requirements by Products

BCBSMA has posted an updated Authorization Requirements by Products. To view the complete list, click here.

Medical Policy Update: Medical and Surgical Management of Obesity including Anorexiants

The coding section has been updated with additional codes. To view the complete policy, click here.

Medical Policy Update: Medicare Advantage Management

The policy has been updated as follows: Clarified prior authorization for policy 107. To view the complete policy, click here.


Medicare Opioid Edits and Programs for 2023

CMS requires certain prospective safety edits. These edits will occur when the member is filling the prescription at the pharmacy. These edits require resolution. The pharmacist at the pharmacy may override some of the edits with appropriate codes, may need to consult with the provider, and may need to inform the provider that a prior authorization is required. Since these are safety edits, they will still apply during a member’s transition period; meaning, the claims will still reject with the edits and require resolution. Buprenorphine for medication-assisted treatment (MAT) is not included in the safety edits. For additional information and to view the notification, click here.

Revised Preventive Services Payment Policy

The Preventive Services Payment Policy has been revised. Updated Unhealthy Alcohol Use in Adults, added Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse for Medicare members, added Screening for asymptomatic bacteriuria in adults, updated Developmental and Behavioral Health Screening in Pediatric Primary Care. For additional information and to view the entire policy, click here.


Medicaid NCCI Policy Manual (Complete Document) Effective Jan. 1, 2023

CMS updates the NCCI Policy Manual for Medicaid Services once a year. The NCCI Policy Manual should be used as a general reference tool that explains the rationale for NCCI edits. The most current policy manual, effective Jan. 1, 2023, was posted on Dec. 1, 2022. Additions and revisions to the manual are noted in red font. To view the notification including links to view the manual by chapter and a link for the complete document, click here.


2023 Locality-Adjusted Payment Rates for Influenza, Pneumococcal and Hepatitis B Vaccine Administration

CMS posted a zip file for 2023 Locality-Adjusted Payment Rates for Influenza, Pneumococcal and Hepatitis B Vaccine Administration for claims with dates of service 1/1/2023-12/31/2023. To view the zip file, click here.

Billing for Providers – Telehealth Services Tip Sheet

There are three types of telehealth services: Asynchronous, Synchronous, and Remote Patient Monitoring. Each type is connected to specific billing and reimbursement rules. For additional information, click here to view the tip sheet.

Notice of New Interest Rate for Medicare Overpayments and Underpayments -2nd Quarter Notification for FY 2023 Trans. R11784FM, CR#13079

Medicare Regulation 42 CFR Section 405.378 provides for the charging and payment of interest on overpayments and underpayments to Medicare providers. The Secretary of Treasury certifies an interest rate quarterly. Treasury utilizes the most comprehensive data available on consumer interest rates to determine the certified rate. Interest is assessed on delinquent debts in order to protect the Medicare Trust Funds. The attached Recurring Update Notification applies to Chapter 3, Section 10. To view the transmittal, click here.

COVID-19 Vaccines and Monoclonal Antibodies (Update)

This update reflects new codes for Moderna and Pfizer-BioNTech pediatric bivalent (updated COVID-19 vaccines) booster dose/-third dose. To view the complete notification, click here.

Harvard Pilgrim Health Care

Telehealth Reimbursed at Pre-Pandemic Rate as of March 1, 2023

Effective for dates of service beginning March 1, 2023, Point32Health will resume our pre-pandemic telehealth reimbursement practices for Harvard Pilgrim Health Care and Tufts Health Plan providers, in keeping with guidance provided by the states we serve. For additional information and to view the entire policy, click here.

Point32Health 2023 Fee Schedule Updates

Fee schedules — including facility, professional (medical and behavioral) and ancillary/allied — are reviewed regularly to ensure that they are comprehensive and consistent with industry standards. For additional information and to view the entire notification, click here.

Synagis Coverage for the 2022-2023 RSV Season

Harvard Pilgrim would like to remind providers of the policy regarding Synagis (palivizumab), an injection of antibodies used to protect high-risk infants from severe respiratory syncytial virus (RSV) disease for the 2022-2023 season. Synagis requires prior authorization and should be reserved for infants with a history of pre-term birth and children with chronic lung disease or congenital heart disease. For members who qualify to receive five doses, the first dose is typically administered at the beginning of November and the last dose at the beginning of March to provide protection into April. For additional information and to view the entire notification, click here.

Tufts Health Public Plan

Tufts Health Public Plans Utilization Review Matrix 2023 Musculoskeletal Surgery (Spine) (NIA Magellan)

Tufts Health Public Plans has posted the most current Utilization Review Matrix 2023 Musculoskeletal Surgery (Spine). To view the list, click here.

Tufts Health Public Plans Commercial, Exchange, and Medicaid Members Only Utilization Review Matrix 2023 Musculoskeletal Surgery (Hip, Knee and Shoulder) (NIA Magellan)

Tufts Health Plan has posted the Utilization Review Matrix 2022 Tufts Health Plan Musculoskeletal Surgery (Hip, Knee and Shoulder). For additional information, click here.

MCO/ACO CBHI Authorization Processes

All authorization parameters below are floors not ceilings. If a provider uses up the units authorized in a given time parameter prior to the end of the end date of the authorization, the provider can contact the MCO/ACO to request additional units. To view the complete form, click here.

Preventive Services Payment Policy Update

Correct formatting error in “lung cancer screening” section, Added codes 92588, 92650, Z00.110, Z00.111, Z01.10, Z01.110, Z01.118, P09.6 to Hearing Screening section. Effective date 12/8/22 – added new codes 91316, 91317, 0164A, 0173A to covid vaccine section. For additional information and to view the entire policy, click here.

Tufts Health Plan

Tufts Health Plan has posted the Utilization Review Matrix 2022

Tufts Health Plan Musculoskeletal Surgery (Hip, Knee and Shoulder). For additional information, click here.

Tufts Health Plan Utilization Review Matrix 2023 Outpatient Interventional Pain Management (IPM) (NIA Magellan)

The matrix attached contains all of the CPT 4 codes for which National Imaging Associates Inc. (NIA) authorizes on behalf of Tufts Health Plan. For additional information and to view the notification, click here.


Medicare 2023

Medicare Part B monthly premiums will be reduced by about $5 per month starting in January 2023 along with a decrease in the deductible, now $226. Total monthly premiums will range from $164.90 – $560.50 depending on taxable income. (Click here to view the slides for a summary).

Medicare Part D income-related monthly premiums will range from $0 – $76.40, again based on taxable income. Remember this premium is “in addition to Part D plan premiums” (ex. If joint tax return is greater than $194,000 and less than $246,000, $12.20 will be added to the monthly Part D plan premium).

In January, Medicare Part D deductible will increase to a maximum $505 which means members may pay the first $505 of pharmacy costs for their medications. This amount may vary by plan.

Other changes include Medicare Part D coverage of Shingles Vaccine given at local pharmacies or billed under Medicare Part D.

Please see the 2023 Medicare Part D Prescription Drug Coverage Patient Handout that can be printed and shared with your patients. Please reach out to if you would like copies sent to your practice.

Accessibility of GLP1-Receptor Agonists:* (see GLP1-RA Conversion Guide).

GLP-1 receptor agonists (GLP-1 RAs) have seen a significant increase in use for select patients with type 2 diabetes (T2DM) and in patients with obesity. Given their rapid uptake by providers and patients, shortages have created a significant access barrier. Wegovy (semaglutide), the newest GLP-1 RA approved for obesity management, has been experiencing sporadic supply issues since 2021. Saxenda (liraglutide), another GLP-1 RA indicated for obesity management, is a potential alternative but is also having supply issues. Saxenda and Wegovy are the only GLP-1 RAs that should be used for obesity management in patients without T2DM.

Ozempic (semaglutide) and Trulicity (dulaglutide), two GLP-1 RAs approved for the treatment of T2DM, are experiencing similar supply issues for all strengths. A potential contributing factor is patients being switched from Wegovy to Ozempic for off-label treatment of obesity management, which may be contributing to the Ozempic shortage and thus leading to a switch from Ozempic for T2DM to Trulicity. Trulicity is the only other once-weekly GLP-1 RA with cardiovascular benefits in T2DM. Doses of Ozempic and Trulicity are being released intermittently as they become available (see GLP1-RA Conversion Guide).

Potential alternative GLP-1 RAs in patients with T2DM include Victoza (liraglutide), Bydureon (exenatide extended-release), and Byetta (exenatide). None of these has reported supply issues at this time, however Victoza is the only one of the three to have demonstrated cardiovascular benefits in T2DM (see GLP1-RA Conversion Guide).

Mounjaro (tirzepatide) is a GLP-1 RA/gastric inhibitory peptide (GIP) RA recently approved for the treatment of T2DM. While Mounjaro has demonstrated weight loss in these patients, it is currently not approved for obesity management and should be reserved for use in T2DM.

Another barrier to GLP-1 RA access is the requirement of a prior authorization (PA) for coverage in most cases, depending on the indication and various requirements. GLP-1 RAs indicated for T2DM often require a trial of one or two other medications, including metformin, for initial coverage. GLP-1 RAs indicated for obesity may require documentation of one or all of the following: elevated body-mass index (BMI, usually greater than 30), attestation of use of lifestyle modification, and documented failure of lower-tier alternatives. Additionally, a follow-up PA may also be required after several months to ensure the medication has resulted in some weight loss (usually at least 5%).

*reported in November and December 2023 BILHPN Newsletters

BILHPN Pharmacy Newsletters:

Each month the BILHPN Pharmacy Team publishes a valuable newsletter with current pharmacy related issues. You can access them by using the Website under Pharmacy Resources*

*please note, a password is now required to log into Pharmacy Resources on the website. If assistance is needed, please contact Alycia Messelaar at

For more information please contact Carol Freedman at or at 978-380-4089.


February is American Heart Month

FACTS: White Coat Hypertension

  • 20-30% of patients with elevated BP in office are normotensive out of office
  • “Should be suspected in any patient with markedly elevated office BP in absence of end-organ damage”
  • Can be confirmed with normal home BPs
  • Can be minimized by nurse/MA taking BP
  • Can be minimized with automatic cuffs, and multiple readings while provider steps out

Factors that can Increase Blood Pressure Readings:

Key Take-Aways:

  • Automated home blood pressure cuffs are a helpful tool for managing hypertension
  • Many factors can increase blood pressure results. Minimize these factors to ensure accuracy
  • Recheck a 2nd blood pressure >139/89


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

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

Virtual Networking videos from NEPHO providers can be found at

Please reach out to Alycia Messelaar at if you are interested in being featured in a Virtual Networking video. 

Click here for the PDF version of the updated PHO Directory as of January 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!

  • Monthly BILHPN Pharmacy Newsletters
  • Monthly BILHPN BMC WellSense MassHealth ACO Newsletter
  • 2022 Affiliation Status Letters
  • Boston Children’s Hospital
    • BCHMedEd January Newsletter and RSV CME Course
    • Updated Urgent Access Guide and BCH Pedi Environmental Health Grand Round sessions for January and February
  • Slide deck from BILHPN | Health Plan Orientation – Provider Office Staff Zoom Webinar | Point32Health – HPHC – TUFTS – 1.12.2023
  • MassHealth ACO: Upcoming member communications
  • Beth Israel Lahey Health Performance Network CDI Newsletter – Jan. 2023
  • Banking ACH changes

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

Health Plan Participation Grid

The Northeast PHO has updated the Health Plan Participation document that highlights the NEPHO contracted health plans and products and the referral requirements for each plan. Please share this document internally by way of the website link or by printing this PDF.

Referral Simplification Summary

The BILHPN PCP to BILHPN Specialist administrative referral process for Blue Cross Blue Shield of MA, Harvard Pilgrim Health Care, or Tufts Health Plan members can be found by clicking here to view and print.

Covid-19 Public Health Emergency Continues

On January 11, 2023, the U.S. Health & Human Services Secretary Xavier Becerra once again extended the COVID-19 Public Health Emergency (PHE) declaration for another 90 days. Additional information can be found here.


Below is a list of the Beth Israel Lahey Health Performance Network Quality Strategic Priorities for 2023. All of the payers will be focusing on diabetes and hypertension. Throughout the year the Quality Team will provide more information about the quality measures and our performance.


Care Retention

In 2023, retaining care within the NEPHO/BILHPN network will continue to be a major focus of our Referral Management Team. Keeping care local leads to improved quality and patient care due to closer communication between Primary Care Providers and Specialists

NEPHO/BILHPN adopted Out of Network guidelines, including the ones listed below, to ensure we continue to improve care retention within our system.

  • Request for same day or backdated referrals.
    • In general, these requests will not be approved, as patients need to request referrals from the PCP with adequate prior notice
    • In some circumstances, a referral may be approved with education of the patient as to the correct process (Pay and Educate). These circumstances may occur where the patient was not aware of the referral requirements or where the Medical Director for Referral Management and the PCP agree it is appropriate.
  • Referral requested by an Out of Network facility or provider
    • These will not be approved. Referrals are to be sought by the patient and authorized or not authorized by the PCP
  • Out of Network Referral by an In Network Specialist
    • Referrals must be authorized by PCP or PCP Practice team (Central Referral Team is included in “PCP Practice Team” definition)

The workflow will remain the same and each referral will be reviewed centrally.

Please do not hesitate to contact Ann Cabral, Manager, Referral Services at or 978-808-5379 if you have any questions.


OPTUM NEWSLETTERJanuary – Annual Wellness Visits

Clinical Documentation Improvement – Tips and Tricks

Ali Wiklund, Northeast PHO Director of Population Health, created clinical documentation tips for patients with morbid obesity and diabetes to improve NEPHO patient risk scores. Click here to view and print these tips.

Please reach out to Jessica Bryan at to discuss setting up a time for additional clinical documentation improvement opportunities for you or your practice staff. 


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

  • Dr. Alyssa Handler is an excellent doctor who listens carefully and looks at the whole of me to provide the best possible care.
  • Dr. David Driscoll is always a very kind, caring, concerned doctor.
  • Dr. Deborah Shih is always attentive at visits – She is very knowledgeable about my health care questions and options available to me. Staff are pleasant and respectful.

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

  • Dr. Spencer Amesbury is always respectful and knowledgeable.
  • Dr. Gail Ellis is hands down the best PCP I’ve had. She really listens and gives such up to date medical advice on so many different things.

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

  • Dr. Andrew Lenhardt and staff have consistently provided excellent care to me.
  • Dr. Daniel McCullough is everything that a good, caring, thorough professional physician should be. He is, by far, the best I have dealt with in my 84 years. That same professionalism is reflected in his entire staff of caring people.

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

  • Dr. Kristina Jackson is an amazing provider. She always takes her time and truly listens to what I have to say.

Beth Israel Lahey Health Primary Care, Danvers – 5 Federal Street 

  • I met Dr. Brent Fryling and was very impressed with his kindness and compassion. I am going to enjoy my relationship with his office.
  • Always have a great visit with Dr. Margaret Legner. Practices and service are always professional, kind, caring, and consistent.

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

  • Dr. Amy Esdale has been my primary care since she started her practice. She is very caring and professional. I was upset and she made me feel at ease. She is wonderful.

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

  • Dr. Victor Carabba is an excellent primary care provider. He listens to his patients and carefully explains everything. Beth Israel Lahey Health Primary Care is very fortunate to have a caring provider. He has been my doctor for many years keeping me healthy.

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

  • Dr. Laurence Gordon was very friendly and listened very carefully to me. Could not be better!

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

  • Dr. Jana Oettinger was totally up to date on all aspects of my health conditions upon entering the exam room. She had obviously reviewed my file before examining me. She made me comfortable right from the start. I am very impressed with Dr. Oettinger & will gladly recommend her to all potential patients.
  • Dr. Matthew Plosker was incredibly helpful and very knowledgeable. I will definitely be requesting him for future appointments.
  • I am very happy with Dr. Matthew Plosker, he is always very professional and very familiar with my issues.

Blackburn Primary Care, Gloucester – 1 Blackburn Drive

  • Very pleased. Dr. Jay Isaac took as much time as I needed to explain some of my new problems. As always very knowledgeable and pleasant.

Cape Ann Medical Center, Gloucester – 1 Blackburn Drive

  • Always a pleasure to deal with Dr. James Maguire and staff. Thorough exam and discussion of results in a pleasant manner. I always refer to Dr. Maguire because that’s who I see.
  • Always a pleasure to visit Dr. Janet Doran. She is an excellent listener as well as a fine diagnostician.
  • Dr. Shawn Pawson is a fantastic, effective, compassionate, intelligent doctor and I am so grateful that I have him as my PCP.
  • Excellent visit. I definitely would recommend Dr. Shawn Pawson to other friends/family.
  • I do like Dr. Yuliya Mandel, she has been my primary care physician since I moved 10ish years ago. She listens to me, very important.
  • I really appreciate how Dr. Yuliya Mandel answers my questions and has seen me in person.

Cape Ann Pediatricians, Gloucester – 298 Washington Street 

  • As always, every time we come here, we are more than satisfied. Great staff, great doctor! Have nothing but amazing things to say about Dr. Brian Orr and this practice.

Danvers Family Doctors, Danvers – 140 Commonwealth Avenue

  • Dr. Subroto Bhattacharya is a warm knowledgeable physician who truly cares for his patients. He really listens and is very wise with treatment suggested.

EMTAR Healthcare, Inc., South Hamilton – 205 Willow Street

  • You could not find a better doctor than Dr. Michael Edwards. He is extremely knowledgeable and thorough. I like that he has medical students because they are learning from the very best!

Essex County Primary Care, South Hamilton – 42 Asbury Street 

  • All went well, as expected. Dr. Nicholas Avgerinos is always very helpful, pleasant, kind and professional.

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

  • Dr. Leonard Horowitz is the best. Our family loves him. He really listens to the patient.

North Shore Pediatrics, Danvers – 480 Maple Street 

  • Dr. David Danis – Everyone is always so friendly and professional. We love this practice!
  • Dr. Shannon Dufresne is absolutely amazing! She listens, cares, is able to explain medical things easily. I could go on and on!


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:

Theresa Horgan, BILH Primary Care, Gloucester, was recognized for her patient comment “the staff, especially Theresa are very compassionate and friendly”.

Diannetti Jimenez, BILH Primary Care, Danvers, received a Teamwork award for her dedication, professionalism and outstanding teamwork at her practice. 

Theresa Horgan, BILH Primary Care, Gloucester

Diannetti Jimenez, BILH Primary Care, Danvers

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!