MedicaidPrior AuthMedium impact
Managed Care Entity Bulletin 128: Ending the Suspension of 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
MassHealth is reinstating referral requirements for most services starting August 1, 2025, ending COVID-19 flexibilities that suspended these requirements. However, urgent care services will remain exempt from referral requirements and must be billed with specific place of service codes (20 for professional claims, admit code 02 for institutional claims).
Action Required
By August 1, 2025: Billing team must reinstate referral requirement workflows for all MassHealth managed care members except for urgent care services. Update billing system to ensure urgent care services use place of service code 20 for professional claims and admit code 02 for institutional claims. Train staff on new referral processes and update encounter forms to remind providers of referral requirements for non-urgent services.