On March 20, 2020, as part of MassHealth’s COVID-19 response, the Executive Office of Health and Human Services suspended referral requirements for MassHealth covered services for the Primary Care Accountable Care Organizations (ACO) and the Primary Care Clinician (PCC) Plan.
Effective August 1, 2025, MassHealth will reinstate referral requirements for services provided to members in the PCC plan or a Primary Care ACO, as outlined in 130 CMR 450.118(J): Referral for Services and 130 CMR 450.119(I): Referral for Services.
For more information, please review All Provider Bulletin 403: Ending the Suspension of Primary Care Clinician Plan & Primary Care ACO Referrals and Updating Referral Requirements for Urgent Care Services: https://www.mass.gov/lists/403-through-300.
Claims submitted to MassHealth for services that require a referral must include an authorized referring provider’s national provider identifier (NPI). The referring provider must also be enrolled with MassHealth for the claim to be payable. When the PCC and Primary Care ACO referrals are reinstated on August 1, 2025, billing providers must include the NPI of an authorized referring provider who is enrolled with MassHealth. This NPI must appear on every claim with a service that requires a referral for the claim to be payable.
For questions or concerns:
LTSS providers, please contact the LTSS Provider Service Center at (844) 368-5184 or support@masshealthltss.com.
All other providers, please contact MassHeath at (800) 841-2900 or provider@masshealthquestions.com.