MedicaidPrior AuthHigh impact
All Provider Bulletin 403: Ending the Suspension of Primary Care Clinician Plan & Primary Care ACO Referrals and Updating Referral Requirements for Urgent Care Services
MassHealth·MA·Managed Care
Effective date
Aug 1, 2025
We identified it
Jun 18, 2026
Summary
Starting August 1, 2025, MassHealth will reinstate referral requirements for Primary Care Clinician Plan and Primary Care ACO members that were suspended during COVID-19. However, urgent care services will be exempt from referral requirements if billed with specific codes (place of service 20 for professional claims, admit code 02 for institutional claims).
Action Required
By August 1, 2025: Billing team must update system to require referrals for all services provided to MassHealth PCC Plan and Primary Care ACO members, except urgent care. Ensure urgent care claims use place of service 20 (professional) or admit code 02 (institutional). Verify all referral claims include the NPI of an authorized, enrolled MassHealth referring provider. Update staff training and encounter forms to reflect reinstated referral requirements. Claims without proper referrals will be denied.