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BMC HEALTHNET PLAN
MEMBER HANDBOOK
A list of your member benefits and services (Covered Services List)
is included as a separate document. Make sure you keep this
Member Handbook and the Covered Services List together.
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
INTRODuCTION
Welcome to BMC HealthNet Plan (the Plan)! This Member handbook will help you understand
the benefits and Covered Services you get as a Plan Member. It will also explain how to contact
us if you have any questions.
You can call BMC HealthNet Plan’s Member services department to have a Spanish ver-
sion of this Member handbook sent to you. Or, call to have this Member handbook read
to you in any language. All written materials sent to Members are available in Spanish.
They can also be read to you in any language. Call the Member services department at
the number at the bottom of each page:
• For copies of materials in Spanish
• For oral (spoken) translations into other languages
• To have written materials read to you
• To receive a copy of this Member handbook in braille, large font or to request
American Sign Language video clips.
All translation services for Members are free of charge.
English and Spanish versions of this Member handbook are also available on our Web site,
bmchp.org.
Some words in this Member handbook have special meaning. These words are capital-
ized throughout the handbook. You can look up the meaning of these words in the glos-
sary in section 15 of the Member handbook.
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
TABLE OF CONTENTS
For a list of your Member benefits and Covered Services, see
the Covered Services list included with this Member handbook.
Section 1. Overview of BMC HealthNet Plan Membership ..................................................1
What is BMC HealthNet Plan? .............................................................................................1
New Member orientation ..................................................................................................... 1
Doctors and other healthcare Providers near you ...............................................................1
Provider Directory ................................................................................................................1
Provider information .............................................................................................................1
Your MassHealth coverage ..................................................................................................1
About your Enrollment options ............................................................................................1
Special help if you have certain medical conditions ........................................................... 1
Get More ............................................................................................................................ 2
Section 2. Your BMC HealthNet Plan ID card ....................................................................... 2
A Member ID Card will be mailed to you ............................................................................. 2
Lost your Member ID Card? ................................................................................................ 2
Section 3. Contacting your Providers, contacting us .......................................................... 2
Your healthcare Providers ................................................................................................... 2
BMC HealthNet Plan .......................................................................................................... 2
Benefits, Eligibility and healthcare questions ..................................................................... 3
Care when you travel outside our Service Area ................................................................. 3
Section 4. Your Benefits ......................................................................................................... 4
How to obtain your benefits ............................................................................................... 4
Specialty care ..................................................................................................................... 4
Receiving care from Providers within the BMC HealthNet Plan Network .......................... 4
When Prior Authorization is needed for visits to Specialists .............................................. 4
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
TABLE OF CONTENTS
When Prior Authorization is needed for other services................................................... 6
Timeframes for Prior Authorization Decisions ................................................................ 6
Receiving care from Providers outside of the BMC HealthNet Plan Network ................ 6
Coverage if you change plans .........................................................................................7
If you get a bill for Covered Services .............................................................................. 7
Extras “free” for our Members ........................................................................................8
Process to evaluate new technology .............................................................................. 8
Section 5. Your Primary Care Provider (PCP) ............................................................ 8
Primary Care Provider (PCP) ...........................................................................................8
Picking a PCP ................................................................................................................. 8
Providers who are PCPs ................................................................................................. 8
Call your PCP for an appointment .................................................................................. 9
Call your PCP first when you’re sick – unless you think it’s an Emergency ....................9
Changing your PCP ........................................................................................................ 9
Getting a Second Opinion ...............................................................................................9
Section 6. Your Health Care ..................................................................................... 9
Emergencies and Urgent Care ........................................................................................9
Behavioral Health care .................................................................................................. 10
Health Risk Assessment ................................................................................................11
How long it should take to get care ..............................................................................11
Children in the care or custody of the
Department of Children and Families (DCF)...................................................................12
Utilization Management .................................................................................................12
Quality Improvement Program........................................................................................12
Clinical Practice Guidelines ...........................................................................................12
Transportation assistance .............................................................................................. 2 1
Staying healthy ..............................................................................................................13
Prescription medication coverage .................................................................................13
If you can’t pay the Co-payment ...................................................................................14
Mail order pharmacy program .......................................................................................14
Pharmacy programs ......................................................................................................14
Medicare part D .............................................................................................................15
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
TABLE OF CONTENTS
Section 7. Pregnancy, Family Planning, Preventive Care and Well-Child Care,
EPSDT, Children’s Behavioral Health Initiative and Early Intervention ........................... 15
Pregnancy (prenatal) care ................................................................................................. 15
Make an appointment with an obstetrician/gynecologist (OB/GYN) ............................... 15
Your OB/GYN doctor ........................................................................................................ 16
Family Planning Services .................................................................................................. 16
Preventive and well child care for all children ................................................................. 16
Preventive Pediatric Health Care Screening and Diagnosis (PPHSD) services ................ 16
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services .................... 17
Children’s Behavioral Health Initiative (CBHI).................................................................... 17
Dental care for children .................................................................................................... 17
Additional services for children ........................................................................................ 18
Section 8. Care Management .............................................................................................. 18
Care Management Education and Wellness .................................................................... 19
Care Management Health Care Coordination .................................................................. 19
Care Management Select ................................................................................................ 19
Behavioral Health Care Management .............................................................................. 19
Intensive Clinical Management ........................................................................................ 19
Section 9. Rights and Responsibilities .............................................................................. 20
Section 10. Inquiries, Grievances and Appeals ................................................................. 22
Section 11. Notice of Privacy Practices ............................................................................. 27
Section 12. Advance Directives .......................................................................................... 31
Section 13. Disenrollment ................................................................................................... 31
Section 14. Coordination of Benefits/Subrogation .......................................................... 32
Section 15. Glossary ............................................................................................................ 33
Section 16. Index .................................................................................................................. 38
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
SECTION 1 Providers throughout most of
Massachusetts. Our Service Area
printed Provider Directory, call our
Member services department
includes the following regions of
Overview of Your Massachusetts: Western, Central,
Provider information
If you want more Provider infor-
BMC HealthNet Plan Southeastern, Northern and Greater
mation -- such as any malprac-
Boston. We work with doctors,
Membership hospitals, and other Providers to
tice, medical school or residency
information -- contact the Mas-
What is BMC HealthNet Plan? offer healthcare services within our
sachusetts Board of Registra-
BMC HealthNet Plan is a Managed Service Area. This means that you
tion of Medicine. The number is
Care plan. Being part of a Man- don’t need to travel a long way to
1-800-377-0550; or go to www.
aged Care plan means that you get your health care.
massmedboard.org and click on
will choose a Primary Care Pro-
“Physician Profiles.”
vider (PCP) who will manage your You can find out more information
health care and coordinate your about our Service Area and how Your MassHealth coverage
care with Specialists, if necessary. BMC HealthNet Plan contracts As a Member of BMC HealthNet
You can choose your PCP from with healthcare Providers by call- Plan, you keep all your MassHealth
BMC HealthNet Plan’s Provider ing our Member services depart- coverage and benefits; therefore,
Network. See section 5 of this ment. you must be MassHealth eligible
Member handbook for more infor- in order to be covered by BMC
Provider Directory
mation about PCPs. HealthNet Plan. Most people have
Our Provider Directory shows
to have their MassHealth eligibility
New Member orientation BMC HealthNet Plan’s Network
re-determined every year. So make
BMC HealthNet Plan will contact Providers, including:
sure you immediately fill out and
you to welcome you to the Plan • Primary Care Sites return your Eligibility Review Veri-
and go over all your benefits so • Primary Care Providers (PCPs) fication (ERV) form to MassHealth
you understand how to use them. • Hospitals when you get it in the mail. If you
This is also a good time for you • Specialty Providers need another form or help filling
to ask any questions you may • Behavioral Health Providers out the form, call BMC HealthNet
have about your coverage. If we
Plan’s Member services depart-
can’t reach you, please call the You are free to choose among our ment, or call the MassHealth cus-
Member services department and Network of Primary Care Providers tomer service center. The numbers
a representative will be happy to in our Service Area. The Provider are at the bottom of every page of
speak with you. To make sure we Directory also has a complete list this handbook.
can reach you, always call our of our Network pharmacies, facility
Member services department and and ancillary Providers, hospital About your Enrollment options
MassHealth customer service Emergency services, Emergency If you have questions about your
if you change your address or Services Program (ESP) Providers health plan enrollment options
phone number. If you don’t keep for Behavioral Health, and durable with MassHealth – including BMC
MassHealth up to date on your medical equipment suppliers. HealthNet Plan – please call the
contact information, you could MassHealth customer service cen-
lose your MassHealth and BMC In the Provider Directory, you can ter. The number is at the bottom
HealthNet Plan eligibility. You also find information about Provid- of the page. You may change your
can find contact information at ers, including contact information, Managed Care plan at any time
the bottom of every page in this languages spoken, handicap ac-
handbook. Special help if you have
cessibility, hours of operation and,
certain health conditions
Doctors and other healthcare when applicable, hospital affilia-
BMC HealthNet Plan offers special
Providers near you tion.
health programs to Members with
We contract with doctors, certain health conditions. For
hospitals, pharmacies, Behavioral To access our Provider Directory,
example, we have programs for
Health and other healthcare go to bmchp.org. For a copy of a
Members with:
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
1
• asthma correct. If it’s not correct, or if you Member, call our Member services
• cancer did not get an ID Card, please call department. The number is at the
• congestive heart failure the Member services department bottom of this page. We will verify
• depression promptly. (Remember: If you your Eligibility for the Provider.
• diabetes change your address and phone
SECTION 3
• high blood pressure number, you need to call the
• HIV/AIDS Member services department and
• obesity you need to call the MassHealth
• or who are pregnant customer service center to update Contacting your
your information.)
See Section 8 for more Providers, contacting us
information on our Care Manage- Your healthcare Providers
ment programs. If you have a
chronic or long-term condition that • You should write down your
is not listed here, BMC HealthNet PCP’s phone number and put
Plan will work with you and your it somewhere where you can
health care Provider to manage find it quickly. Call your PCP
your care. first for health-related ques-
tions or problems, except in
Get more! an Emergency. In case of an
Members of BMC HealthNet Emergency, you should call
Plan get all the benefits that 911 or go to the nearest hos-
MassHealth provides. See your pital Emergency room. See
Your ID Card has important phone
Covered Services list in this our online Provider Direc-
numbers for contacting us. And it
handbook for a list of your BMC tory at bmchp.org for a list of
says what to do when you need
HealthNet Plan benefits. Plus statewide hospital Emergency
Emergency or urgent Care. (See
BMC HealthNet Plan Members get: rooms.
Section 6 for more information
• Free health care information about Emergency or urgent Care.) • If you have a Behavioral Health
from highly trained registered Emergency, call 911 or go to
nurses through our 24-hour Always carry your BMC HealthNet the nearest hospital Emergency
Nurse Advice Line Plan ID Card to receive healthcare room. You can also contact the
• Free infant/toddler car seats or pharmacy services. You should Emergency Services Program
• Free bicycle helmets for kids also always carry your MassHealth (ESP) Provider in your area. See
• Free manual breast pumps for ID Card. our online Provider Directory at
nursing mothers bmchp.org for a list of statewide
Lost your BMC HealthNet ESPs.
SECTION 2
Plan Member ID Card?
To replace your BMC HealthNet BMC HealthNet Plan
Plan ID Card, call the Member • Call our Member services
Your BMC HealthNet services department. You can also
order a new ID Card from our Web
department if you have ben-
efit questions. You will find the
Plan ID Card site, bmchp.org. Call MassHealth phone number at the bottom of
to order a new Mass Health card. this page.
A BMC HealthNet Plan Member The number is below. Even if
ID Card will be mailed to you • Our Web site, bmchp.org, con-
you don’t have your ID Card, a tains a lot of important informa-
Every BMC HealthNet Plan
healthcare Provider should never tion, such as:
Member receives a BMC
deny care to you or your BMC
HealthNet Plan identification (ID)
HealthNet Plan covered family o Find out about
Card (ID Card) like the one shown
Members. If a Provider refuses your coverage
below. Please check your ID Card
to treat you or a covered family o Search for a
to make sure the information is
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
2
healthcare Provider Member services depart- You can also call the Nurse Advice
o Find a provider’s hospi- ment. The number is at the Line from BMC HealthNet Plan.
tal affiliation bottom of the page. The number is 1-800-973-6273.
o Find health information o If you have questions about You can get healthcare information
o Read our Member your MassHealth benefits, from a highly trained registered
newsletter you may call us or call nurse, 24 hours a day, seven days
o Find a pharmacy MassHealth at one of the a week. Some examples of health
near you following numbers: BMC problems or questions include:
HealthNet Plan at 1-888-
You may also send an e-mail to us 566-0010 (TTY/TDD 1-866- • feeling sick
from our Web site, bmchp.org. 765-0055) or MassHealth • dizziness
at 1-888-841-2900 (TTY/ • back pain
If you don’t have a computer at • coughing
home, you can go to your local TDD 1-800-497-4648).
• baby is crying and feels hot
library for free internet access. • colds
• Health-related questions
Benefits, Eligibility and o If you think you’re having a Remember: The Nurse Advice Line
healthcare questions health (medical or Behav- can help you, but it should not
We want to make sure it’s easy ioral Health) Emergency*, take the place of your healthcare
for you to get the information call 911 or go to the nearest Provider.
you want. Here is some helpful hospital Emergency room.
information. (See Section 6 for more Care When You Travel Outside
information on Emergency our Service Area
• MassHealth Eligibility ques-
care.) Remember to call When Members are away from
tions
your PCP about your Emer- home, BMC HealthNet Plan will
If you have questions about your
gency as soon cover only Emergency, Post-
MassHealth Eligibility, you may call
as possible. stabilization and urgent Care
us or call MassHealth at one of the
o If you are having a Behav- services*. To ensure coverage, be
following numbers:
ioral Health Emergency*, sure to take care of your routine
you can also call your health care needs before traveling
BMC HealthNet Plan at 1-888-
local Emergency Services outside of BMC HealthNet Plan’s
566-0010 (TTY/TDD 1-866-765-
Program (ESP) Provider. Service Area.
0055) or
Often ESPs can be a bet- *Only Emergency, Post-
MassHealth at 1-888-841-2900
ter choice than a hospital stabilization and Urgent Care
(TTY/TDD 1-800-497-4648).
Emergency room. Remem- health services provided in the
ber to call your PCP, and United States or its territories
• Benefits questions
your Behavioral Health are covered. You should still
o Refer to your Covered Ser-
Provider, if you have one, seek care in an Emergency
vices list in this handbook
about your Emergency as when you are outside the United
for more information about
soon as possible. States, but be advised that BMC
your benefits. Your Covered
o If you are not having a HealthNet Plan will not cover
Services list will also show
medical or Behavioral these services.
you which benefits are
Health Emergency, always
covered by BMC HealthNet If you need Emergency or urgent
call your healthcare Pro-
Plan and which are covered Care while you are temporarily
vider first if you have ques-
by MassHealth. When you outside the BMC HealthNet Plan
tions about your health or
want to speak with some- Service Area, go to the nearest
if you need urgent Care or
one about the benefits and doctor or hospital Emergency
Routine Care.
Covered Services you get room. You do not have to call
as a BMC HealthNet Plan your Primary Care Provider before
Member, please call our seeking Emergency or urgent Care
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
3
while outside the BMC HealthNet
Plan Service Area. You or a family SECTION 4 certain disorders with bones and
joints. Pulmonologists treat asth-
member should call your Primary ma and other breathing problems.
Care Site (or your Behavioral Your Benefits Psychiatrists specialize in treating
Health provider in a Behavioral How to obtain your benefits mental health conditions.
Health Emergency) within 48 hours The Covered Services list in this
of receiving out-of-area care. Member handbook shows that If you think you need to see a
BMC HealthNet Plan covers most Specialist, you should first call
BMC HealthNet Plan will cover all of your benefits. But MassHealth your PCP. Your PCP can help you
Medically Necessary Emergency, also directly covers some benefits identify your specialty care needs
Post-stabilization and urgent Care even though BMC HealthNet Plan and refer you to an appropriate
Services delivered outside the Ser- may coordinate them. That’s why Specialist. Your PCP may also help
vice Area. BMC HealthNet Plan will you should always carry both you with any follow-up care that is
not cover: your BMC HealthNet Plan and important for your health and re-
• Emergency services provided MassHealth ID Cards. covery, both while being treated by
outside the united States or its a Specialist and afterward. There-
territories. Always check your Covered Ser- fore, it is important that you talk
vices list to see what services are with your PCP about your special-
• Tests or treatment that your ty care needs and treatment even
covered and what services are not
Primary Care Provider asked for after you are feeling better and no
covered. And, always show your
before you left the Service Area. longer need those services.
BMC HealthNet Plan ID Card to
• Routine Care or follow-up care receive your Plan Covered Servic-
that can wait until your return Receiving care from
es and benefits. If you need help
to the Service Area, such as Providers within the BMC
getting any benefits or Covered HealthNet Plan Network
physical exams, flu shots, stitch Services, please call our Member
removal, mental health counsel- Healthcare Providers who have
services department. Your Primary contracts with BMC HealthNet
ing. Care Provider is the best person Plan are considered Network
• Care that you knew you were to tell you if you need any of these Providers. These include both
going to get before you left the services. Primary Care Providers and
Service Area such as elective Specialists. You must always
surgery. If you need a ride to a health care receive your care from Network
appointment, and if you’re eligible Providers, except as described
A Provider may ask you to pay
for non-emergency transportation in “Receiving care from Providers
for care received outside of BMC
services, we can help arrange for outside of the BMC HealthNet
HealthNet Plan’s Service Area
it. Just call our Member services Plan Network” later in this section
at the time of service. If you pay
department and a representative
for Emergency Care, Post-stabi-
can assist you. (See Section 6 for When Prior Authorization is
lization Care or urgent Care that
more information on transportation needed for visits to Network
you receive while outside of BMC
assistance.) Specialists
HealthNet Plan’s Service Area
but within the united States or Specialty care • Your PCP coordinates all your
its territories, you may submit a There may be times when you may care, including specialty care.
Claim to BMC HealthNet Plan to need to see a Specialist. Your PCP or Specialist does not
be reimbursed. See the section on need to get a Prior Authoriza-
A Specialist is a healthcare Provid-
“If You Receive a Bill” to find out tion from BMC HealthNet Plan
er who is trained to provide specif-
how to submit a Claim. You may before you visit most Special-
ic, often more detailed, treatments
also call the Plan’s Member ser- ists in BMC HealthNet Plan’s
than your PCP. For example, a
vices department for help with any Provider Network. For example,
cardiologist is a doctor who spe-
bills that you may receive from a your PCP or Specialist does not
cializes in treating heart problems.
Provider. need a Prior Authorization for
Orthopedists specialize in treating
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
4
you to visit a Specialist within exam, including any follow-up
the Network if your PCP and Prior authorization is NOT required obstetric or gynecological ser-
the Specialist are both affili- in the following cases: vices determined to be medi-
ated with the same hospital or cally necessary as a result of
• In an Emergency such exam
if the Specialist is affiliated with • To see a BMC HealthNet Plan • Medically necessary evalua-
Boston Medical Center. Network Specialist affiliated tions and related health care
However, there are some situa- with Boston Medical Center services for acute or Emergen-
tions, described below, • To see a BMC HealthNet Plan cy gynecological conditions
where your PCP or Specialist Network Specialist affiliated • To get a mammogram
does need to get Prior Authoriza- with the same hospital as your • To get Family Planning Ser-
tion from BMC HealthNet Plan PCP vices from any BMC HealthNet
before you see a Specialist within • To see a BMC HealthNet Plan Plan Network Family Plan-
BMC HealthNet Plan’s Provider Network Specialist affiliated ning Services Provider or
Network. with any BMC HealthNet Plan MassHealth-contracted Family
contracted hospital not listed Planning Services Provider
Your PCP or Specialist must get above • For the first 12 visits to a Be-
Prior Authorization before you see • To go to any BMC HealthNet havioral Health Provider
a Specialist who is affiliated with Plan Network obstetrician,
any of the following hospitals, un- gynecologist, certified nurse Before you visit a Specialist, you
less your PCP and the Specialist midwife or family practitioner should always check with your
are both affiliated with the same who is affiliated with any Net- PCP or the Specialist to find out if
hospital: work hospital for the following he or she has gotten Prior Authori-
types of care:
• Beth Israel Deaconess Medical • Maternity care
Center (all locations)
• Routine annual gynecologic
• Carney Hospital
• Children’s Hospital If you would like to go Does my PCP or Net- Will BMC HealthNet Plan
(all locations) to a Network Specialist work Specialist have to approve a Prior Authori-
• Mount Auburn Hospital affliated with: get Prior Authorization zation for my visit?
from BMC HealthNet
• St. Elizabeth’s Medical Center Plan before I visit this
• Tufts Medical Center network Specialist?
• Women and Infants Hospital of Boston Medical Center NO NOT APPLICABLE
Rhode Island
the same hospital as my NO NOT APPLICABLE
PCP
When prior authorization is re-
any network hospital - NO NOT APPLICABLE
quired, it will be granted except those hospitals
for specialty care with specialists listed in the box below
affiliated with the above hospitals • Beth Israel YES* BMC HealthNet Plan will
when the specialty care is not avail- Deaconess Medical approve your visit only
able from: Center-(all locations) (* unless the network if the specialty care you
• Carney Hospital specialist is affiliated need is not available
• Children’s Hospital- with the same hospital from a network Special-
• a specialist affiliated with Bos- (all locations) as your PCP.) ist affiliated with Boston
ton Medical Center; or • Mount Auburn Hos- Medical Center or a BMC
• a BMC HealthNet Plan Net- pital HealthNet Plan Network
• St. Elizabeth’s Medi- Specialist affiliated with
work Specialist affiliated with cal Center the same hospital as the
the same hospital as the Mem- • Tufts Medical Center Member’s PCP
ber’s PCP • Women and Infants
Hospital of Rhode
Here is a chart to further explain island
how this works:
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
5
zation from BMC HealthNet Plan, if when an Authorization request the Plan does not make the Autho-
necessary. may be expedited (processed rization decisions within the above
fast) by determining that fol- timeframes. (For more information
You can look up hospital affilia- lowing the standard timeframe on how to file a Grievance or an
tions for PCPs and specialists on could seriously jeopardize your Internal Appeal, please see Sec-
our website. You can also call our life or health, or your ability to tion 10 “Inquiries, Grievances and
Member services department for get, maintain or regain maxi- Appeals.”)
help with this. mum function.
We will send a written notice to
When Prior Authorization is These Authorization decision time- you, and your Authorized Rep-
needed for other services frames may be extended to up to resentative, and the requesting
In addition to Prior Authorization an additional 14 calendar days if Provider of any decision to deny
needed to see certain Network you or your Provider requests an an Authorization request, or to
Specialists, there are other extension, or the Plan has a good authorize a service in an amount,
services that must be authorized reason to believe that: duration, or scope that is less than
in advance by BMC HealthNet requested. You, or your Authorized
Plan, MassHealth or Beacon • The extension is in your best Representative, have the right to
Health Strategies in order for these interest. file an Internal Appeal if the Plan
services to be covered. (Beacon • The Plan needs additional denies an Authorization request or
Health Strategies is responsible information that we think, if we authorizes a service amount, dura-
for authorizing Behavioral Health receive it, will lead to approval tion or scope that is less than what
- mental health and substance of your request. was requested. (For more infor-
abuse - services for Members). • Such outstanding information mation on how to file a Grievance
is reasonably expected to be or an Internal Appeal, please see
The Covered Services list in received by the Plan within 14 Section 10 “Inquiries, Grievances
this Member handbook shows calendar days. and Appeals.”)
the services that require Prior
Authorization. When a service Receiving care from
If BMC HealthNet Plan asks for Providers outside of the BMC
requires Prior Authorization, your an extension of the Authorization
Provider must submit a request for HealthNet Plan Network
timeframes, we will send you, and Providers who do not have
those services to BMC HealthNet your Authorized Representative, a
Plan, Beacon Health Strategies contracts with BMC HealthNet
written notice. If you or your Au- Plan are considered “out-of-
(for Behavioral Health services) or thorized Representative disagree
MassHealth. Network Providers.” You are not
with this decision, you or your covered for services provided
Authorized Representative may by an out-of-Network Provider,
Timeframes for Prior
file a Grievance in writing, over the except in any of the following
Authorization Decisions
phone or in person. Our Member cases:
Prior Authorization decisions are
services department representa-
made by a healthcare professional
tives can help you with this. (For • An Emergency
that has appropriate clinical
more information on how to file a • Your Network Primary Care
expertise within the following
Grievance or an Internal Appeal, Provider (PCP) has gotten
timeframes:
please see Section 10 “Inquiries, Prior Authorization from BMC
Grievances and Appeals.”) HealthNet Plan
• Standard Authorization deci-
• Family Planning Services with
sions: Within 14 calendar days
We will send a written notice to any MassHealth-contracted
after the request is received.
you, and your Authorized Repre- provider of Family Planning
• Expedited (fast) Authorization
sentative, if we did not meet these services
decisions: Within 72 hours
timeframes. You, or your Autho- • If BMC HealthNet Plan is
after the request is received.
rized Representative, have the unable to provide a specific
Only a Provider can recom-
right to file an Internal Appeal if covered service through a
mend, or the Plan can decide,
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
6
BMC HealthNet Plan Network sure that you have Authorization Mail any bills for medical
Provider. Requests must go before you see a Provider that is services to:
through the Prior Authorization not part of the Plan’s Network.
process described above. If You may ask your PCP to arrange Member Services Department
BMC HealthNet Plan deter- this or call the the Plan’s Member BMC HealthNet Plan
mines that the specific covered services department. Two Copley Place, Suite 600
service is medically necessary When your Provider is no longer Boston, MA 02116
and not available through a in BMC HealthNet Plan’s Network
BMC HealthNet Plan Network because they have been disen- Mail any bills for Behavioral
provider, BMC HealthNet Plan rolled from the Plan’s Network Health services to:
will adequately cover the ser- for reasons not related to quality Beacon Health Strategies, LLC
vice in a timely manner with an of care or Fraud, BMC HealthNet 500 Unicorn Park Drive,
out-of-Network Provider for as Plan may be able to provide cover- Suite 401
long as the service is medically age for: Woburn, MA 01801
necessary and not available
through a BMC HealthNet Plan • up to 30 calendar days if the • You cannot be charged for:
Network Provider. Provider is your PCP or up to Emergency or Post Stabiliza-
90 calendar days if the Provid- tion Care services provided
Coverage if you er, including a PCP, is provid- in the united States and its
changed plans ing you with active treatment territories. Post Stabilization
To ensure continuity of care, for a chronic or acute medical Care services are the services
there are some times when BMC condition or until that active you get after your Emergency
HealthNet Plan may be able treatment is completed, which- condition is brought under
to provide coverage for health ever comes first. control so that your condi-
services from a Provider who • If you are in your second or tion can then stay stable. For
is not part of our Network. For third trimester of your preg- example, if you’re treated for a
new Members who were already nancy, you may remain under Behavioral Health Emergency
receiving care from a Provider the care of your current OB/ by an Emergency Services
who is not part of BMC HealthNet GYN (even if out of Network) Program (ESP) Provider, you
Plan’s Network when they join the through delivery and follow-up may also be covered for the
Plan: within the first six weeks of follow-up services such as
delivery. Your second trimester community crisis stabilization
• If you are in your second or is the start of your 4th month services once your Emergency
third trimester of your preg- of pregnancy based on the has been dealt with.
nancy, you may remain under expected delivery date. • Services you get from a BMC
the care of your current OB/ • With respect to a terminal ill- HealthNet Plan Provider or
GYN (even if Out-of-Network) ness, coverage shall apply to an out-of-Network Provider
through delivery and follow-up services rendered until death. if these services were prior
check-up within the first six authorized by the Plan. It is the
weeks of delivery. Your second If you get a bill for services responsibility of the Provider to
trimester is the start of your 4th If you get a bill for a Covered obtain prior authorization from
month of pregnancy based on Service, here’s what you should BMC HealthNet Plan when
the expected delivery date. do: needed.
• For a limited period, if you are • Services provided by a
• Print the name of the Member
receiving ongoing covered MassHealth Provider when
who received the care, and his
treatment or management of those services are covered
or her BMC HealthNet Plan
chronic issues, including previ- directly by MassHealth.
Member ID Card number on
ously authorized services for • Family Planning Services
the bill.
Covered Services. received from any MassHealth
• Make a copy of the bill for your
contracted Family Planning-
records.
It is still your responsibility to make Services Provider.
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
7
However, care that is not cov- coverage. (Efficacy means that • Keep your medical records
ered by BMC HealthNet Plan or the technology works.) Such • Write prescriptions
MassHealth may be your respon- technologies include medical • Request Prior Authorizations
sibility to pay. We can help you and Behavioral Health therapies, from BMC HealthNet Plan,
figure this out. devices, surgical and diagnostic when necessary
If you have questions, please call procedures and medications. • Respond to your phone calls
our Member services department. about your medical needs or
We’ll help you resolve the problem. The review process by the Plan’s problems, even after business
medical staff includes consulting hours.
Extras, “free” for our with medical experts who have
Picking a PCP
Members expertise in the new technology;
Call us if you need help choosing
• Infant/toddler safety car seats research and review of published
a PCP. And if you already have
– If you’re having a baby, call peer-reviewed medical literature
a PCP when you call, we want
the Member services depart- and reports from appropriate gov-
to make sure that we have the
ment to find out how to get ernmental agencies (such as the
correct information for our records.
your free convertible car seat. federal Food and Drug Administra-
If you haven’t picked a PCP yet,
You can get the seat up to tion), and policies and standards
we have a long list of PCPs and
45 days before your due of nationally recognized medical
we’ll help you choose one for
date. associations and specialty so-
you and for each BMC HealthNet
• Bicycle helmets for kids – Kids cieties. The information is then
Plan-enrolled family Member. Even
who are Members of BMC presented to the Plan’s internal
though you can pick a PCP from
HealthNet Plan can get a free committees who are responsible
anywhere in our Network, it makes
bike helmet. Call our Member for making final decisions con-
sense that you pick one who
services department to find out cerning coverage of the medical
is near you. You should call us
how to get the helmet. technology.
immediately to pick a PCP if you
• Manual breast pumps – A
SECTION 5
haven’t already done so. Or check
nursing mother needs a pre-
out our online Provider Directory
scription from her healthcare
at bmchp.org. You can also have
Provider for a manual breast
pump. Call the Member ser- Your Primary Care a printed Provider Directory sent
to you by calling our Member
vices department to find out Provider (PCP) Services department. BMC
how to get the manual breast
Primary Care Provider (PCP) HealthNet Plan will assign a PCP
pump.
Every BMC HealthNet Plan to any Member who does not pick
• The Nurse Advice Line from
Member needs to have a Primary one within 15 days of Effective
BMC HealthNet Plan can help
Care Provider (PCP). He or she Date of enrollment in the Plan. You
you answer your health ques-
is your personal doctor or nurse can change your PCP at any time
tions 24-hours a day, seven
days a week. The number is practitioner. Your PCP will do Providers who are PCPs
1-800-973-6273. Remember: many things for you and your There are a few different kinds of
the Nurse Advice Line can help BMC HealthNet Plan enrolled healthcare Providers who may act
you, but it should not take the family Members: as PCPs:
place of your Primary Care • Provide or coordinate all your • Family practice Providers treat
Provider. care, except in an Emergency adults and children. They can
• Treat you for your basic health also provide women’s health
Process to evaluate new needs and problems services for pregnant women.
technology • Refer you to other healthcare • General practice Providers
BMC HealthNet Plan reviews Providers and Specialists treat adults and children.
new medical technologies and • Admit you to the hospital and • Internal medicine Providers
new uses for existing medical arrange for your hospital care, treat adults over the age of 17
technologies for safety and if necessary years. (A medical doctor who
efficacy before we determine
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
8
practices internal medicine is you and your family’s health his- have. We can also arrange for you
called an “internist.”) tory, the better he or she can man- to get a second opinion from a
• Pediatric Providers treat chil- age your care. Adults should visit provider outside of our network. In
dren and young adults up to their PCPs at least once a year for both cases, BMC HealthNet Plan will
age 21 years. a comprehensive annual exam. pay for your Second Opinion visit.
• Nurse practitioners – registered Infants, children and pregnant
nurses with advanced training women should see their PCPs
in the treatment of many health
issues.
more often. Please see Section
7 for information on how often to SECTION 6
• Obstetricians/Gynecolo- see your healthcare Provider.
gists treat women’s health
Your Health Care
and reproductive issues. (they Call your PCP first when Emergencies and Urgent Care
must also be contracted with you’re sick – unless you think Emergencies*
BMC HealthNet Plan as a PCP. it’s an Emergency Whether you have a medical
Check your online Provider Your PCP will provide and coor- Emergency or a Behavioral Health
Directory at bmchp.org to dinate all your care, except in an Emergency, you should seek im-
see if they are listed as a PCP.) Emergency. If you think you are mediate care when there’s no time
having an Emergency, call 911 or to call your health care Provider.
Each family Member enrolled in BMC go to the nearest hospital Emer-
HealthNet Plan must have a PCP If . gency room listed in our online You do not need approval from
everyone in your family wants the Provider Directory at bmchp.org. your health care Provider to seek
,
same PCP you can choose a family If it’s a Behavioral Health Emer-
Emergency care. And you’re cov-
practice or general practice Provider gency, call 911, go to the near-
ered for Emergency care 24 hours
to be the PCP for each BMC Health- est hospital Emergency room, or
a day, seven days a week, even
Net Plan family Member. contact the nearest Emergency if you’re outside BMC HealthNet
Call your PCP for an Services Program (ESP) Provider Plan’s Service Area or need to
appointment listed in both our online and print see an out-of-Network Provider*.
When you become a BMC Health- Provider Directories. If you need a You’re also covered if a BMC
Net Plan Member, you should printed directory, call Member Ser- HealthNet Plan representative tells
make an appointment to see your vices and they will send you one. you to seek Emergency care. Note:
PCP for a checkup. Your PCP’s At all other times, you should call You cannot be denied Emergency
name is on your BMC HealthNet your PCP’s office. There’s always a care based on your diagnosis
Plan ID Card. Make sure you write healthcare Provider on call for you, (your illness or condition).
down your PCP’s phone number 24 hours a day, seven days a week
and put it where you can find it to help you. *However, you are not covered
quickly. Changing your PCP for Emergency care outside of
We want you to be happy with the United States or its territo-
Call your PCP’s office. Tell the of- your PCP. It is important to have ries. You should still seek Emer-
fice staff this will be your first visit an ongoing relationship with your gency care when you’re outside
with this PCP, or that this is your PCP for continuity of your health- the country, but be aware that
first visit with the PCP using your care and wellness. However, if you the services you receive will not
BMC HealthNet Plan insurance. If feel the need to change your PCP, be covered by BMC HealthNet
you have any problems making an you can pick a new PCP at any Plan.
appointment, call our Member ser- time by calling our Member ser- The Emergency care doctor or
vices department. If it’s your first vices department. Provider treating you is responsible
visit with your PCP, most likely you Getting a Second Opinion for deciding when you are stable
will get a physical exam. Your PCP You may ask for a Second Opinion enough to be transferred or dis-
will ask you questions about your from another BMC HealthNet Plan charged. The Provider’s decision
health and your family’s health. is binding on those responsible for
Provider about any health care that
The more your PCP knows about coverage and payment. This means
your Provider thinks you should
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
9
that BMC HealthNet Plan and cies. This list does not include all if you’re out of town or out of the
anyone responsible for covering or the health Emergencies that you Service Area, you should call your
paying for your care must follow might have. Call 911 if you think PCP if an urgent Care condition
the direction the Provider decides. you are having an Emergency. occurs. You can call your PCP 24
hours a day, seven days a week. If
You are also covered for ambu- Examples of medical your PCP is not available, a cov-
lance transportation and Post Emergencies ering doctor or other healthcare
Stabilization Care services that Provider will call you back.
are related to an Emergency. Post • Broken bones
Stabilization Care services are the • Throwing up continuously Behavioral Health care
services you get after your Emer- • Throwing up blood Choosing Behavioral Health ser-
gency condition is stabilized so that • Convulsions vices
your condition can then stay stable. • Chest pain BMC HealthNet Plan has part-
For example, if you’re treated for • Fainting or dizzy spells nered with Beacon Health Strat-
a Behavioral Health Emergency at • Heart attacks egies (Beacon) to manage and
an Emergency Services Program • Loss of consciousness coordinate the Behavioral Health
(ESP) provider, you are also cov- • Poisoning (mental health and substance
ered for the follow-up services you • Serious accidents abuse) services for Members and
will need once your Emergency has • Severe burns manage the Behavioral Health Pro-
been dealt with. This follow-up care • Severe pain vider network. Beacon is a Mas-
might include outpatient visits or • Severe headaches sachusetts based company with
treatment at another facility. • Severe wounds an excellent reputation for coor-
• Heavy bleeding dinating quality Behavioral Health
In a medical Emergency: Call • Shortness of breath services.
911 or immediately seek care in • Stroke (this includes numb-
any hospital Emergency room. A ness or difficulty with speech) You can find a list of Behavioral
statewide list of Emergency rooms • Sudden change of vision Health Providers in our online
is in your BMC HealthNet Plan • Sudden, severe pain or pres- Provider Directory at bmchp.org. If
Provider Directory in the “Statewide sure in or below the chest you need a printed Provider Direc-
Emergency Care by Hospitals” and tory, call our Member Services
in our online Provider Directory at Examples of Behavioral Health department.
bmchp.org Emergencies
• Wanting to harm yourself Behaviroal Health services are
In a Behavioral Health Emer- • Wanting to harm other people available by “self-Referral”. This
gency: Call 911, go to the nearest means that you can go to a BMC
hospital Emergency room or im- Urgent Care HealthNet Plan Behavioral Health
mediately contact the Emergency An urgent Care condition is a Provider when you want to. You
Services Program (ESP) Provider health problem that’s serious – but can find the listing of these Provid-
in your area. A statewide list of that you do not think is an Emer- ers in our online Provider Directory
ESPs is in your Provider Directory gency. Your PCP must see you or you can ask family members,
in the “Statewide Behavioral Health within 48 hours after you request guardians, a community agency, or
Emergency Services Programs” for an urgent Care appointment. your Provider (including your PCP)
Your Behavioral Health Provider to recommend a BMC HealthNet
and in our online Provider Directory must also see you within 48 hours Plan Behavioral Health Provider.
at bmchp.org. for urgent Care for Behavioral No Prior Authorization is needed
Health conditions. If your urgent for up to the first 12 visits to a
Below are some examples of medi- Care condition gets worse before Behavioral Health Provider in our
cal and Behavioral Health Emer- you are seen by your PCP or Be- Network. Your Behavioral Health
gencies. Please note that these are havioral Health Provider, you can Provider will arrange for any need-
only the most common Emergen- go to an Emergency room. Even ed Prior Authorizations beyond the
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
10
first 12 visits. Certain Behavioral It is very important that you fill a week. Members have unrestrict-
Health services, like diversionary out the HRA and return it to us in ed (no limit) access at any qualified
and inpatient, must be authorized the postage-paid envelope that’s Emergency care Provider whether
in advance for them to be cov- provided. You can also complete or not the Providers are part of
ered. The Covered Services List your HRA online via the Member BMC HealthNet Plan’s Network.
in this Member handbook shows self service section at bmchp.org.
the Behavioral Health services that Filling out your HRA DOES NOT Urgent Care
require Prior Authorization. Your affect your MassHealth Eligibility A healthcare Provider must give
Provider should be able to make or your health benefits in any way. you urgent Care within 48 hours of
arrangements for Prior Authori- Please know that we will keep your your request for an appointment.
zation. You can always call the Protected Health Information (PHI)
Behavioral Health Member line confidential. Primary care
(see the phone number listed at Non-urgent, symptomatic care (if
the bottom of this page) if you If you do not fill out your HRA, a you are sick or have other symp-
have any questions about Prior representative from BMC Health- toms that are not urgent): A health-
Authorization for Behavioral Health Net Plan may call you and ask care Provider must give you care
Covered Services. you to give us your Health Risk within 10 calendar-days of your
Assessment information. (See request for an appointment.
Remember, in a Behavioral Health Section 11 for information about
Emergency you should call 911, go your PHI and your rights to keep it Routine, non-symptomatic care (if
to the nearest hospital Emergency private.) The answers you give in you’re not sick and don’t have any
room, or contact the Emergency the Health Risk Assessment help other symptoms):
Services Programs (ESP) Provider us to help you stay healthy, so A healthcare Provider must give
in your area. A statewide list of please complete your HRA. you care within 45 calendar days
Emergency Services Program of your request for an appoint-
(ESP) Providers is in your printed How long it should take ment. That is unless you or your
and online Provider Directory at to get care child needs an appointment as
bmchp.org. When you don’t feel well or when part of the EPSDT (Early and
you really want to see your health- Periodic Screening, Diagnosis and
Note that you are not covered care Provider, you don’t want Treatment) Periodicity Schedule
for Emergency care outside of to wait too long for an appoint- Your child’s health care Provider
the United States or its territo- ment. That’s why we require all can give you more information
ries. You should still seek Emer- of our Providers to comply with about EPSDT schedules. (For
gency care when you’re outside the guidelines that follow. You more information on EPSDT, see
the country, but be aware that shouldn’t need to wait any longer Section 7.)
the services you receive will not than what is listed. If you think that
be covered by BMC HealthNet any of these timeframes have not Routine, first prenatal and first
Plan. been met, then you, or your Au- family-planning visit
thorized Representative, have the Within 10 working days of request-
Health Risk Assessment right to file an Internal Appeal. (For ing an appointment.
Your new-Member materials Appeals information, see Section
include a special form called a 10, “Inquiries, Grievances and Ap- Specialty care
Health Risk Assessment (HRA). peals.”) Non-urgent, symptomatic care (if
The HRA will help us to better you’re sick or have other symp-
understand your health needs – so Getting medical care toms that aren’t urgent): A health-
that we can make sure that we ad- Emergency care care Provider must give you care
dress your health care needs and An Emergency room or other within 30 calendar-days of your
that you’re getting any special care healthcare Provider of Emergency request for an appointment.
you may need. services must give you care imme-
diately, 24 hours a day, seven days Routine, non-symptomatic care
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
11
(if you’re not sick and don’t have or custody of DCF, a healthcare to improve the quality of care and
symptoms): A healthcare Pro- provider must: services that our Members re-
vider must give you care within 60 ceive. For example, in the past the
calendar-days of your request for • Give your child a healthcare Plan focused on improving care
an appointment. screening within seven calen- for Members with diabetes and
dar days after you or the DCF asthma as well as on improving
Getting Behavioral Health care worker asks for it. overall coordination of care and
Emergency Behavioral Health care • Give your child a full medical Member satisfaction with the Plan.
A hospital Emergency room, an exam within 30 calendar days At the end of each year we will
Emergency Services Program after you or the DCF worker evaluate our progress, identify
(ESP) Provider or other healthcare asks for it, unless a shorter opportunities for improvement and
Provider of Emergency services time frame is required by Early establish the following year’s goals
must give you care immediately, and Periodic Screening, Diag- and Quality Improvement program
24 hours a day, seven days a nosis and Treatment (EPSDT)
week. services schedule. (See Sec- Clinical Practice Guidelines
tion 7 for EPSDT information.) BMC HealthNet Plan adopts,
Urgent Behavioral Health Care develops and implements Clinical
A healthcare Provider must give Utilization Management Practice Guidelines (CPGs) rele-
you urgent Care within 48 hours of utilization Management is a vant to its membership for provid-
your request for an appointment. process used by qualified BMC ing appropriate, effective care to
Other Behavioral Health services HealthNet Plan staff to make sure all our Members and includes pre-
A healthcare Provider must give you’re getting the right health care ventive and non-preventive acute
you care within 14 calendar days when you need it. The utilization and long-term clinical services for
of your request for an appoint- Management decision making medical and Behavioral Health
ment. process at BMC HealthNet Plan conditions. CPGs help us estab-
For services described in an follows certain guidelines to en- lish standards of care throughout
Inpatient or 24-hour diversionary courage the right use of services our Provider Network. The Plan
services discharge plan, you must to help ensure positive outcomes adopts Clinical Practice Guidelines
get care within these time frames: for our Members. For example, the from national sources or develops
Plan bases all utilization Manage- guidelines in collaboration with
• For non-24-hour diversionary ment decisions only on the Medi- specialty organizations and/or
services: within two calendar cal Necessity and appropriateness regional collaborative groups. You
days of discharge of care and services, as well as on may request a copy of the Plan’s
• For medication management: the existence of coverage. BMC current CPGs by contacting the
within 14 calendar days of HealthNet Plan does not reward Member services department.
discharge decision makers for issuing deni-
• For other outpatient services: als nor does it offer them financial Transportation assistance
within seven calendar days of incentives that encourage under- As a benefit from MassHealth,
discharge utilization of services. some BMC HealthNet Plan Mem-
• For Intensive Care Coordina- bers may be eligible to have
tion services: within twenty- BMC HealthNet Plan Members can non-Emergency transportation
four (24) hours of Referral, call 1-888-566-0010 to find out the arranged for them to go to health
including self-Referral, offering a status or outcome of utilization re- care visits. This is a service that
face-to-face interview with the view decisions involving their care. BMC HealthNet Plan administers
family. for MassHealth. In order to be
Quality Improvement program eligible for this benefit:
Children in the care or cus- BMC HealthNet Plan’s Quality 1. You do not have a family
tody of the Department of Improvement committee approves member or other person who
Children and Families (DCF): a Quality Improvement program can take you.
If you have children in the care (QIP) annually. This program looks 2. You do not have access to
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
12
public transportation, or there is lier if sexually active) ing a pharmacy, call our Member
a medical reason that you • Breast cancer screening (mam- services department.
cannot use it. mogram) every year over age Paying at the pharmacy
3. Your appointment must be for a 40 (or earlier if there is an im- unless you fall into one of the cat-
Medically Necessary Service. mediate family history of breast egories below, you will need to pay
4. You must see a MassHealth cancer. Breast exams could a Co-payment at the pharmacy
Provider. then be as often as every six for your prescription drugs. Please
months.) refer to your Covered Services list
For more information, contact our • Colorectal cancer screen- for information on Co-pays.
Member services department. You ing every 10 years starting at
should contact the Plan well in age 50 (or earlier if there is Please note that BMC Health-
advance of your appointment so an immediate family history Net Plan Members pay the same
we can process your request. of colorectal cancer. In that Co-payments for prescription
case, exams could be more medications as Members of other
Staying healthy frequent.) MassHealth Managed Care plans.
The best health care happens • Flu shot annually
before you get sick. It’s called • Eye exams once every 24 Some Members don’t have a
preventive care. To help you stay months (or more often if there pharmacy Co-payment
healthy, we’ve put together a chart are certain medical conditions You do not have a pharmacy
to show you all the tests and shots that exist.) Co-payment if:
you and your children should • Dental. (Both adults and chil-
have, depending on age. If you’d dren are eligible for dental ben- • You are under age 19.
like a copy of the chart to be sent efits. Some of these benefits • You are enrolled in MassHealth
to you, please call the Member are covered by BMC Health- because you were in the care
services department. You can also Net Plan. Some are covered and custody of the Department
find the chart on our Web site at by MassHealth. Refer to your Children and Families (DCF)
bmchp.org. Covered Services list in this when you turned 18, and your
Preventive care for adults Member Handbook for details MassHealth coverage was
Routine preventive care is an on dental coverage or call the continued.
important part of staying healthy. Member Services department.) • You are pregnant. (You must
BMC HealthNet Plan encourages tell the pharmacist you’re preg-
all Members to visit their Primary Prescription medication
coverage nant.)
Care Providers for preventive care. • It’s within 60 days following the
Getting your prescriptions filled
Examples of covered preventive month your pregnancy ended.
Your BMC HealthNet Plan health-
care benefits for Members ages 21 • You are receiving family-plan-
care Provider needs to write a
and older include: ning supplies.
prescription for both prescription
medications and over-the-counter • You are in hospice care.
• Physical exams every one to • You are receiving Inpatient care
medications if you need them.
three years in an acute hospital, nursing
BMC HealthNet Plan has more
• Blood pressure monitoring facility, chronic disease hos-
than 1,000 pharmacies in our
at least every two years and pital, rehabilitation hospital, or
Network across Massachusetts –
whenever you have a visit with intermediate-care facility for
including all the major chain stores
your PCP the developmentally delayed.
– where you can pick up your
• Cholesterol screening every • You have met the Co-payment
medications.
five years beginning at age 18 cap for the calendar year (Janu-
or as recommended by your ary through December) of $200.
Our online Provider Directory lets
healthcare Provider We’ll send you a letter to let
you search for a pharmacy in your
• Pelvic exams and Pap smears you know that you’ve reached
area where you can get your medi-
(women) every one to three your cap. If you have reached
cines. If you have problems find-
years (starting at age 21 or ear- the $200 cap and are still being
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
13
asked for Co-payments, you medications in the mail. Once you want more information about the
should send your receipts to sign up, you can refill prescriptions pharmacy programs, visit our Web
BMC HealthNet Plan. (The cap by mail, phone, or online. site at bmchp.org. Or you can call
is the total amount of the Co- our Member services department
payments you’ve been charged, You can find more information and ask for the pharmacy depart-
whether or not you actually paid about the mail-order pharmacy ment.
the Co-payments.) If you don’t program in the special insert that Prior Authorization program – Some
have receipts for all the Co- came as part of this packet. You medications always require Prior
payments you were charged, can also call informedMail™ at Authorization. If your Provider feels
you can request a prescription 1-800-881-1966. that a medication that falls into this
Co-payment record from your group is Medically Necessary for
Pharmacy programs
pharmacist. When you’re ready you, he or she can submit a Prior
While most medications simply
to send in your receipts, call authorization request. That request
require a prescription from
BMC HealthNet Plan’s Mem- will be reviewed by a clinician. If
your healthcare Provider, BMC
ber services department. Ask the medication is Medically Nec-
HealthNet Plan uses a number of
them to send you a copy of a essary, BMC HealthNet Plan will
pharmacy programs to promote
form you’ll need to fill out and cover the medication. If the Prior
the safe and correct use of
include with your receipts when Authorization request is denied,
certain prescription medications.
you send them to us. You can you or your Authorized Represen-
Medications that belong to these
also get a copy of the form at tative can appeal the decision.
programs have Clinical Practice
our Web site, bmchp.org. (You (See Section 10 for Grievances
Guidelines that must be met
will need to download the form and Appeals information.)
before we cover the medication.
to a printer.) The instructions for
You can see which medications Step therapy program – Some
where to send your receipts are
belong to a pharmacy program on types of medications have many
on that form.
the drug list or formulary on the options. Step therapy requires that
If you can’t pay the BMC HealthNet Plan Web site, a Member tries certain first-level
Co-payment bmchp.org. The formulary also medications before BMC Health-
The pharmacy still must fill your lists the drugs that may not be Net Plan will cover another medi-
prescription even if you can’t pay covered. If you want a copy of the cation of that type. If you and your
the Co-payment. However, the formulary, please call our Member Provider feel that a certain first-
pharmacy can bill you later for the services department and ask for level medication is not appropriate
Co-payment. Don’t go without the pharmacy department. to treat a medical condition, your
your medication if you can’t pay Provider can submit a Prior Autho-
the Co-payment. Please call our If your BMC HealthNet Plan rization request. That request will
Member services department if a healthcare Provider thinks it is be reviewed by a clinician. If the
pharmacy refuses to give you your Medically Necessary for you to medication is Medically Necessary,
prescription. take a medication that’s only BMC HealthNet Plan will cover the
covered in one of our pharmacy medication. If the Prior Authoriza-
Mail-order pharmacy program programs, he or she can submit tion request is denied, you or your
BMC HealthNet Plan Members can a Prior Authorization request to Authorized Representative can
have maintenance medications BMC HealthNet Plan. This request appeal the decision. (See Section
sent to their homes instead of will be reviewed by a clinician. If 10 for Grievances and Appeals
filling prescriptions at a local the medication is Medically Nec- information.)
retail pharmacy. Maintenance essary, BMC HealthNet Plan will
medications are those medications New-to-market medication program
cover the medication. If the Prior
that are refilled regularly for – BMC HealthNet Plan reviews
Authorization request is denied,
conditions like diabetes, asthma new medications for safety and
you or your Authorized Represen-
and high blood pressure. You efficacy before we add them to our
tative can appeal the decision.
can enroll with informedMail™ list of medications or formulary.
(See Section 10 for Grievances
order pharmacy to start getting (Efficacy means that the medica-
and Appeals information.) If you
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
14
tion works.) If your Provider feels Administration (FDA) determines 1-877-486-2048); (2) go to Medi-
that a new-to-market medication that certain generic medications care’s Web site at
is Medically Necessary, he or she are therapeutically equivalent (“AB www.medicare.gov; (3) refer to the
can submit a Prior Authorization rated”) to their brand name alter- Medicare and You Handbook; (4)
request. That request will be re- natives. This means that the “AB go to www.cms.com on the inter-
viewed by a clinician. If approved, rated” generic medication is as net. Remember to carry all your ID
BMC HealthNet Plan will cover the effective as the brand name medi- Cards with you when you go to the
medication. If the Prior Authoriza- cation. If your Provider determines pharmacy. When you file a pre-
tion request is denied, you or your that the brand name medication scription, please show your BMC
Authorized Representative can is Medically Necessary, he or she HealthNet Plan Member ID Card
appeal the decision. (See Section may submit a Prior Authorization and your Medicare Prescription ID
10 for Grievances and Appeals request. That request will be re- card.
information.) viewed by a clinician. If approved,
Quantity limitation program – This BMC HealthNet Plan will cover the
program ensures the safe and ap- medication. If the Prior Authoriza-
SECTION 7
propriate use of some medications tion request is denied, you or your Pregnancy, Family
by covering a specific amount Authorized Representative can
that can be dispensed (given by appeal the decision. (See Section Planning, Preventive
the pharmacist) at one time. If 10 for Grievances and Appeals Care and Well Child
your Provider feels that a quantity information.)
greater than the specified amount
Care, EPSDT,
is Medically Necessary, he or she
Medicare Part D
If you are a BMC HealthNet Plan
Children’s Behavioral
can submit a Prior Authorization
Member with Medicare coverage, Health Initative, and
request. That request will be re-
viewed by a clinician. If approved,
your prescription drug benefit Early Intervention
may be covered by a Medicare
BMC HealthNet Plan will cover the
Prescription Drug Coverage (Part Pregnancy (prenatal) care
medication. If the Prior Authoriza-
D) plan. Most of your prescription
tion request is denied, you or your The health care you get while
drugs will be covered under your
Authorized Representative can you’re pregnant (before your baby
Medicare Part D benefit. You
appeal the decision. (See Section is born) is called “prenatal care.”
should have a separate ID card for
10 for Grievances and Appeals This type of care is very important.
your Medicare Prescription Drug
information.) It’s the best way to see how your
Coverage. You will need to show
Specialty pharmacy program – pregnancy is going, if you and your
your Medicare Part D ID card when
This program requires that some unborn baby are getting adequate
filling a prescription. There are
medications be supplied by a nutrition, and to make sure your
some drugs that BMC HealthNet
specialty pharmacy. These medi- baby is developing properly. Your
Plan will continue to cover. For
cations include injectable and health care Provider will monitor
example, BMC HealthNet Plan
intravenous medications that are you throughout your pregnancy to
will continue to cover your over-
often used to treat chronic (ongo- the-counter (OTC) drugs. BMC make sure your baby is developing
ing) conditions like Hepatitis C or properly. Even if you’ve given birth
HealthNet Plan Co-payment
Multiple Sclerosis. These types of exceptions will still apply for BMC before, it’s very important for you
health conditions require additional HealthNet Plan covered drugs. For to get prenatal care throughout
expertise and support. Specialty your current pregnancy.
more information, contact BMC
pharmacies have knowledge HealthNet Plan’s Member services Make an appointment with
in these areas and can provide department. To find out more an obstetrician/gynecologist
additional help to Members and about your Medicare Prescription (OB/GYN)
Providers. Drug Coverage, you may: You need to see an obstetrician
Mandatory generic substitution pro- (1) contact Medicare at (OB) as soon as you can after you
gram – The federal Food and Drug 1-800-633-4227 (TTY: become pregnant. An obstetrician
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
15
is a doctor who’s trained to treat up health care. Or it can be another screening tool
pregnant women and deliver You can get Family Planning chosen by your PCP. You can ask
babies. This type of doctor is Services from your PCP. Or, your PCP which tool he or she will
usually also a gynecologist (GYN). you can get these services from use when screening your child for
That means that he or she is any BMC HealthNet Plan or Behavioral Health concerns.
trained to know all about diseases MassHealth contracted Family
of the female reproductive system. Planning Services Provider. Your Provider will discuss the
The short name for this combined completed screening with you. The
specialty is OB/GYN. These services do not require Prior screening will help you and your
If you think you’re pregnant, you Authorization. You can self-refer doctor or nurse decide if your child
should either: by calling the Family Planning needs further assessment by a Be-
Services Provider directly. Or ask havioral Health Provider or another
your PCP to refer you to a Family medical professional. Information
• Ask your PCP to recommend and assistance will be available if
an OB/GYN doctor (you do not Planning Services Provider. For a
listing of these providers, see our you or your doctor or nurse thinks
need a Prior Authorization). that your child needs to see a Be-
OR online or printed Provider Direc-
tory. havioral Health Provider. For more
• Call a BMC HealthNet Plan information on how to access
OB/GYN doctor and make an Behavioral Health Covered Servic-
Preventive and well-child
appointment. You don’t need care for all children es, or to pick a Behavioral Health
a Prior Authorization to see a Children who are under age 21 Provider, talk to your PCP or call
BMC HealthNet Plan OB/GYN should go to their PCP for check- our Behavioral Health Member line
doctor. But your PCP can pro- ups even when they are well. As listed at the bottom of the page.
vide important health informa- part of a well-child checkup, your BMC HealthNet Plan pays your
tion about you to the OB/GYN child’s PCP will offer screenings child’s PCP for these checkups.
doctor so that you and your to find out if there are any health At well-child checkups, the PCP
unborn baby remain in good problems. These screenings in- can find and treat small problems
health. That’s why you need clude health, vision, dental, hear- before they become big ones. Here
to tell your PCP that you’re ing, Behavioral Health, develop- are the ages to take a child for full
pregnant. mental, and immunization status physical exams and screenings:
screenings.
Your OB/GYN doctor • at 1 to 2 weeks
Early and regular prenatal care is Behavioral Health screenings can • at 1 month
very important to help you have a help you and your doctor or nurse • at 2 months
healthy baby and a safe delivery. to identify Behavioral Health con- • at 4 months
We recommend that you see your cerns early. MassHealth requires • at 6 months
OB/GYN as soon as you think that Primary Care Providers and • at 9 months
you’re pregnant. You should also nurses use standardized screening • at 12 months
see your OB/GYN as often as the tools to check a child’s Behav- • at 15 months
OB/GYN wants to see you. BMC ioral Health during their well-child • at 18 months
HealthNet Plan covers all these visits. The screening tools are ap- • At ages 2-20 – children should
visits. proved by MassHealth. Screening visit their PCP once a year.
tools are short questionnaires or
Family Planning Services checklists that the parent or child Children should also visit their
BMC HealthNet Plan covers Family (depending on the child’s age) fill PCP any time there is a concern
Planning Services that include out and discuss with the doctor or about their medical, emotional or
family planning medical services, nurse. The screening tool might be Behavioral Health needs, even if it
family planning counseling, birth the Pediatric Symptom Checklist is not time for a regular checkup.
control advice, pregnancy tests, (PSC) or the Parents’ Evaluation
sterilization services, and follow- of Developmental Status (PEDS).
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
16
Preventive Pediatric of the service. You and your services including individual, group
Healthcare Screening and PCP can seek help from BMC or family therapy, “diversionary”
Diagnosis (PPHSD) services HealthNet Plan to determine what services such as partial hospi-
for children enrolled in Providers may be available in the talization and Inpatient care. As
MassHealth Basic, Essential Plan’s Network to provide these part of the Children’s Behavioral
or Family Assistance
services and how to use out-of- Health Initiative, Behavioral Health
If you or your child is under
Network Providers, if necessary. services for certain children and
21 years old and enrolled in
Most of the time these services youth under the age of 21 have
MassHealth Basic, Essential or
are covered by your child’s been expanded to include, when
Family Assistance BMC HealthNet
coverage type and are included Medically Necessary, home- and
Plan will pay for all Medically
on your Covered Services list. If community-based services in-
Necessary Services covered under
the service is not already covered cluding mobile crisis intervention,
your child’s coverage type. This
or is not on the list, the clinician in-home therapy, in-home behav-
means that, when a PCP (or any
or Provider who will deliver the ioral services, family support and
other clinician) discovers a health
service can ask BMC HealthNet training, therapeutic mentoring
condition, BMC HealthNet Plan will
Plan for Prior Authorization. BMC and intensive care coordination.
pay for any Medically Necessary
HealthNet Plan uses this process A statewide list of Community Ser-
Services included in your child’s
to determine if the service is vice Agencies can be found in your
coverage type.
Medically Necessary. The Plan printed and online Provider Direc-
Early and Periodic Screening, will pay for the service if Prior tory. For more information, call
Diagnosis and Treatment Authorization is given. If Prior our Behavioral Health Member line
(EPSDT) services for children Authorization is denied, you, or listed at the bottom of the page.
enrolled in MassHealth your Authorized Representative,
Standard or CommonHealth have a right to appeal. (See Sec- Dental care for children
If you or your child is under age tion 10 for more information about MassHealth pays for preventive
21 and enrolled in MassHealth the Appeal processes.) Talk to your and basic services for the
Standard or CommonHealth, child’s PCP, Behavioral Health Pro- prevention and control of dental
BMC HealthNet Plan will pay for vider or other Specialist for help in diseases and the maintenance of
all Medically Necessary Services getting these services. oral health for children.
that are covered by federal
Medicaid law (even if the services Children’s Behavioral Health Your child’s PCP will give a dental
are not specifically mentioned in Initiative (CBHI) exam at each well-child checkup.
your Covered Service list). This The Children’s Behavioral Health When your child is three years old
coverage includes health care, Initiative is an inter-agency (or earlier if there are problems) his
diagnostic services, treatment and initiative of the Commonwealth’s or her PCP will suggest that you
other measures needed to correct Executive Office of Health and take your child to the dentist at
or improve deficits and physical Human Services whose mission least twice a year.
and Behavioral Health illnesses is to strengthen, expand and
and conditions. When a PCP or integrate Massachusetts state When your child goes for routine
any other clinician discovers a services into a comprehensive, exams, the dentist will give a full
health condition, BMC HealthNet community-based system of care, dental exam, teeth cleaning and
Plan will pay for any Medically to ensure that families and their fluoride treatment. It’s important
Necessary Services covered children with significant behavioral, that your child gets the following
under Medicaid law. The treatment emotional and mental health needs dental care:
must be delivered by a Provider obtain the services necessary
who is qualified and willing to for success in home, school and • A dental checkup every six
provide the service. In addition community. months starting no later than
a physician, nurse practitioner, age three.
or nurse midwife must support BMC HealthNet Plan provides a • Other dental treatments need-
in writing the Medical Necessity full range of Behavioral Health ed, even before age three,
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
17
if your child’s PCP or den- vices under federal law. Our Care Management program
tist finds problems with your includes you, your health care
child’s teeth or oral health. Early intervention services Providers, and us, working together
for children with growth or for you to be healthy. BMC Health-
Your child’s dental health may developmental problems Net Plan care managers (or Bea-
be improved by having fluoride Some children need extra help for con care managers, if Behavioral
varnish applied to his or her teeth. healthy growth and development. Health) will be in touch with you to
This can be done by a dentist or Providers who are early check on your progress and help
other healthcare Provider. Fluo- intervention Specialists can help coordinate care with all necessary
ride varnish is mostly for children them. Some of these Providers are: health care Providers.
up to age 3. But it is allowed for We also help you learn what ben-
Members up to age 21 if they • Social workers
• Nurses efits and community resources
don’t have access to a dentist. It’s are available because we want
best to have the varnish applied • Physical, occupational and
speech therapists to help you with more than just
when the child is very young. That health care. Our experienced staff
means as soon as the front teeth can link you with services such as
begin to show at around age six All of these Providers work with
children under three years old – transportation to health care ap-
months. pointments, food stamps, housing
and their families – to make sure
a child gets any extra support and emergency shelter, assistance
Children who are under age 21 with utilities, and support groups.
and enrolled in MassHealth Stan- necessary. Some of the services
are given at home. And some are These community resource ser-
dard or CommonHealth can get vices are available to all Members,
all Medically Necessary Services at early intervention centers.
Talk to your child’s PCP as soon not just those enrolled in Care
covered under Medicaid law. This Management.
includes dental treatment even if as possible if you think your child
the service is not otherwise cov- has growth or development prob- Medical Care Management, in-
ered by MassHealth. lems. Or contact your local early cluding disease management,
intervention program directly. consists of three program levels to
Children who are under age 21 make sure you receive the neces-
SECTION 8
and enrolled in MassHealth Basic, sary level of Care Management.
Essential or Family Assistance can The three levels are:
get all Medically Necessary Ser-
vices covered under their cover- Care Management • Care Management Education
age type. This includes dental and Wellness
treatment. BMC HealthNet Plan is committed • Care Management Health Care
to giving you, our Members, the Coordination
Talk to your child’s PCP or dentist information and tools you need • Care Management Select
for help in getting these services. to build and maintain a healthy In addition to our medical Care
lifestyle. Our Care Management Management program, Beacon
Please note: program is free for Members Health Strategies (Beacon) offers
• Children do not need Pri- (adults and children) and is just a BMC HealthNet Plan Members Be-
or Authorization to see a phone call away. havioral Health Care Management
MassHealth dentist. Our experienced staff includes and Intensive Clinical Manage-
• Children can visit a dentist registered nurses, licensed social ment (ICM) services. For Members
before age three. workers, and trained Care Man- with both medical and Behavioral
agement Specialists. Our staff Health care needs, BMC Health-
Additional services for works with you to help you under- Net Plan’s and Beacon’s Care
children stand and get the right services Management teams will work
Children under age 21 years are and information so you can man- together to ensure full coordination
entitled to certain additional ser- age your condition and be healthy. of care.
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
18
Care Management Education Care Management Select with certain Behavioral Health
and Wellness Care Management Select manages conditions. Our care managers
This level of Care Management Members with complex medical are licensed Behavioral Health
offers educational materials, tools,
conditions. If you are at high risk clinicians that are trained to help
and resources for wellness and for problems because of your you with your Behavioral Health
prevention. The goal is to help youhealth condition or have complex care needs. Beacon can help
learn and follow new and easy medical needs or special health with you with finding a Behavioral
ways to manage specific illnesses care needs, you may be enrolled Health counselor near you or
such as diabetes, asthma, and in Care Management Select. This explaining available treatment
cancer. You can access these level gives you all the information options. Some of the conditions
resources by logging on to and tools you need to manage followed in this program are:
bmchp.org and clicking on Care your condition, but includes more
Management under the Member frequent check-ins from a care • Depression
pages. BMC HealthNet Plan’s manager, including in-person • Emotional distress significantly
online Wellness Center also has visits at home or in the community impacting your relationships,
helpful information for Members as needed. A Care Management school, work, job performance,
on how to stay healthy. team, including registered nurses, difficulty with sleep or eating
pharmacists, and other health care patterns
Care Management Health Providers help with your medical • Mental health needs such as
Care Coordination and social needs. They also bipolar disorder, mood dis-
The Health Care Coordination level educate you about what you need orders, psychotic disorders,
offers Members a more involved to know about managing your schizophrenia
approach. Care managers work condition, arranging for care, and • Substance use or misuse such
with you and a team of health coordinating services and medical as alcohol, pain medications,
care Providers to help you be as equipment. The team works illegal drugs
healthy as possible. This involves together with you to set health
an assessment of your condition, related goals and work towards To learn more:
coordination of care, and review them.
of available benefits. Your care • Call 1-888-217-3501 for Be-
manager can help you set up Our Care Management program havioral Health Care Manage-
services such as family support is free and voluntary. Your par- ment
and community resources. ticipation in the program does not
replace the care and services that Intensive Clinical
Our care managers help you come you receive from your PCP and Management
up with your individual care plan. other health care Providers. En- Beacon also offers an Intensive
By following this care plan, you try into the program may happen Clinical Management program
will learn more about your condi- through completing your Health (ICM) to provide additional sup-
tion while building skills to lead Risk Assessment, our claims in- port. This is a Care Management
a healthy lifestyle. Some of the formation, a referral from a hospi- program provided by Beacon for
conditions followed in this pro- tal Care Manager or one of your BMC HealthNet Plan Members
gram are: providers, or self- referral. who are experiencing complex
• Asthma Behavioral Health or psychosocial
• Diabetes To learn more: conditions, sometimes in addi-
• Congestive heart failure • Call 1-866-853-5241 for medi- tion to medical concerns. ICM is
• HIV/AIDS cal Care Management. a voluntary, flexible, short-term
• Obesity program to meet the individual
• Pregnancy Behavioral Health Care needs and promote your optimal
• Hypertension Management Behavioral Health. Both adults and
• Breast cancer Beacon offers support to BMC children can receive ICM services.
HealthNet Plan Members The program is offered by licensed
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
19
Behavioral Health clinicians who Specialist for treatment that your or visit BMC HealthNet Plan
provide services by phone and PCP cannot provide. or Beacon Health Strategies
during face to face meetings with (for Behavioral Health). Call
Your Rights
Members and their health care the Member services depart-
1. You have the right to be treated
Providers. ment if you need help with this
with respect and with recogni-
ICM care managers work with you service.
tion of your dignity and right to
to advocate for your needs and 9. You have the right to choose
privacy. (See Section 11 “No-
link you to services. We will work your own Primary Care Provid-
tice of Privacy Practices”.)
to ensure you receive coordinated er (PCP) and you can change
2. You have the right to be told
care, discharge planning after a your PCP at any time. You
about and understand any ill-
Behavioral Health care admission, must call the Member services
ness you have.
and resources and support in your department if you want to
3. You have the right to be told in
community. With your permission, change your PCP.
advance – in a manner you un-
we will collaborate with your PCP 10. You have the right to receive
derstand – of any treatment(s)
and/or other health care Provid- health care within the time-
and alternatives that a Provider
ers and family members in order frames described in the “How
feels should be done.
to assist you. Our ICM care plans Long It Should Take To Get an
4. You have the right to take part
are individually developed with you Appointment” part of Section
in decisions regarding your
and your Behavioral Health care 6, and to file an Internal Appeal
health care, including the right
Providers and establish goals and if you do not receive your care
to refuse treatment as far as
the resources you need to achieve within those timeframes.
the law allows, and to know
the goals. 11. You have the right to voice a
what the outcome may be.
For more information about Be- complaint and file a Grievance
5. You have the right to have an
havioral Health Care Management with the BMC HealthNet Plan
open and honest discussion
or ICM: Member services department,
of appropriate or Medically
Beacon Health Strategies, and/
Necessary treatment options
• Call our behavioral or MassHealth customer ser-
for your health conditions,
health member line at vice center about services you
regardless of cost or benefit
1-888-217-3501 (24 hours a received from the Plan or from
coverage. You may be respon-
day/7 days a week) a health care Provider. You also
sible for payment of services
• Or visit our Web site: have the right to Appeal cer-
not included in the Covered
www.bmchp.org tain decisions made by BMC
Services list for your coverage
HealthNet Plan or Beacon
type.
Health Strategies (for Behav-
SECTION 9 6. You have the right to expect
your healthcare Providers to
keep your records private, as
ioral Health). The reasons for
Grievances and Internal Ap-
peals are described in Section
Rights and well as anything you discuss
10, “Inquiries, Grievances and
Responsibilities with them. No information will
be released to anyone without
Appeals.”
12. You have the right to talk about
As a Member of BMC HealthNet your consent, unless required
your health records with your
Plan, you have certain rights con- by law.
Provider and obtain a complete
cerning your health care. You also 7. You have the right to request
copy of those records. You
have certain responsibilities to the an interpreter when you re-
also have the right to request a
Providers who are taking care of ceive health care. Call the
change to your health records.
you. Member services department if
13. You have the right to know and
Regardless of your health con- you need help with this ser-
receive all of the benefits, services,
dition, you cannot be refused vice.
rights and responsibilities you have
Medically Necessary treatment. 8. You have the right to request
under BMC HealthNet Plan and
But your PCP may refer you to a an interpreter when you call
MassHealth.
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
20
14. You have the right to have your from BMC HealthNet Plan and remember that refusing treat-
Member Handbook and any change to another MassHealth ment recommended by your
printed materials from BMC health plan by calling the healthcare Provider might harm
HealthNet Plan translated into MassHealth customer service your health.
your primary language, and/ center. 9. You should authorize your PCP
or to have these materials 21. You have the right to receive to get copies of all your health
read aloud to you if you have information about BMC Health- records.
trouble seeing or reading. Oral Net Plan, our services, and 10. You must receive all your
interpretation services will be Providers, and your rights and health care from BMC Health-
made available upon request responsibilities. Net Plan Providers, except
and free of charge. 22. You have the right to make in cases of Emergency or
15. You have the right to ask for recommendations about our Family Planning Services or
a Second Opinion about any Rights and Responsibilities unless BMC HealthNet Plan
health care that your PCP statement. provides a prior authorization
advises you to have. BMC for out-of-Network care. For
HealthNet Plan will pay for the Your Responsibilities services not covered by BMC
cost of your Second Opinion 1. You should tell your healthcare HealthNet Plan that you get
visit. Provider your health com- using your MassHealth Card,
16. You have the right to receive plaints clearly and provide as you may receive care from any
Emergency care, 24 hours much information as possible. MassHealth contracted Pro-
a day, seven days a week. 2. You should tell your healthcare vider.
Please see the “Emergencies” Provider about yourself and 11. You must not allow anyone
section for complete informa- your health history. else to use your BMC Health-
tion. 3. You should talk to your PCP Net Plan or MassHealth ID
17. You have the right to be free about seeking the services of cards to obtain healthcare
from any form of physical re- a Specialist before you go to services. See the “Reporting
straint or seclusion that would a hospital (except in cases of Health Care Fraud” section
be used as a means of coer- Emergencies or when you refer that follows.
cion, force, discipline, conve- yourself for certain Covered 12. You must notify BMC Health-
nience or retaliation. Services). Net Plan’s Member ser-
18. You have the right to freely 4. You should treat your health- vices department and the
exercise these rights without care Provider with dignity and MassHealth customer service
adversely affecting the way respect. center when you believe that
BMC HealthNet Plan and its 5. You should keep appoint- someone has purposely mis-
Providers treat you. ments, be on time, and call in used BMC HealthNet Plan or
19. You have the right to receive advance if you’re going to be MassHealth benefits or ser-
health treatment from BMC late or have to cancel. vices.
HealthNet Plan Providers 6. You should learn about your 13. You must notify BMC Health-
without regard to race, age, health problems and any Net Plan’s Member ser-
gender, sexual preference, recommended treatment, and vices department and the
national origin, religion, health consider the treatment before MassHealth customer service
status, economic status, or it’s performed. center if you change your ad-
physical disabilities. And no 7. You should partner with your dress or phone number.
Provider should engage in any healthcare Provider and work
You are responsible for payment of
practice, with respect to any out treatment plans and goals
services not included in the Cov-
BMC HealthNet Plan Member, together.
ered Services list for your cover-
that constitutes unlawful dis- 8. You should follow the in-
age type.
crimination under any state or structions and plans for care
federal law or regulation. that you and your healthcare Reporting healthcare Fraud
20. You have the right to disenroll Provider have agreed to, and If you know of anyone trying to
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
21
commit healthcare Fraud, please immediately or, at the latest, within Representative (see description
call our confidential compliance one business day of the day we above) have the right to file
hotline at 1-888-411-4959. You receive your Inquiry. We will let a Grievance if you are not
do not need to identify yourself. you know about the outcome/ satisfied with any aspect of BMC
Examples of healthcare Fraud resolution on the day your Inquiry HealthNet Plan’s or Beacon
include: is resolved. To make an Inquiry, Health Strategies’ operations or
call the Plan’s Member services interactions, or with the quality of
• Receiving bills for healthcare department or Beacon Health care or services you receive from a
services you never received Strategies (for Behavioral Health). Provider. A Grievance can also be
• People loaning their health The phone numbers are at the filed when we:
insurance ID cards to others bottom of the page
for the purpose of receiving • Extend the timeframes to pro-
healthcare services or pre- Authorized Representative cess a Prior Authorization re-
scription medications for Grievances and Internal quest and you, or your Autho-
• Being asked to provide false or Appeals, and Board of rized Representative, disagree
Hearings
misleading healthcare informa- with those decisions.
An Authorized Representative is
tion • Do not approve your request
someone you have authorized, in
for an Expedited (fast) Internal
writing, to act on your behalf with
SECTION 10
Appeal and processes it as a
respect to a Grievance, Internal
standard Internal Appeal, and/
Appeal, or Office of Medicaid’s
or
Board of Hearings (BOH) Appeal.
Inquiries, Grievances If your Authorized Representative
• Extend the timeframes to pro-
cess your Internal Appeal and
and Appeals is your family member, you can
you, or your Authorized Repre-
have him or her represent you
We want you to contact us if you sentative, disagree with those
in multiple Grievance or Internal
have any concerns with your care decisions.
Appeal cases. The family member
or services. Our Member services can have a standing Authorization
department will help you resolve For an explanation of these time-
until you send the Plan a letter
your concerns. The phone num- frames, see the sections “How
informing us that the Authorization
bers are at the bottom of the page. Long Should It Take to Get an Ap-
has been revoked. If you pick an
pointment”, “Services that Require
Authorized Representative who
You also have the right to voice Prior-Authorization” and “How
is not a family member, you must
any concerns to MassHealth at Quickly Will You Receive a Deci-
get a new Authorization each
any time. You may call a cus- sion on Your Internal Appeal”
time. We must receive this written
tomer service representative at Authorization before our deadline When can the Plan or Beacon
the MassHealth customer service for resolving your Grievance Health Strategies dismiss
center at one of the numbers at or Standard Internal Appeal your Grievance?
the bottom of the page. expires. We can help you write an We may dismiss your Grievance
Authorized Representative letter, if someone else files it on your
Inquiries
or we can mail you an Authorized behalf and we did not receive
An Inquiry is any question or
Representative form for you to your written Authorization for that
request that you may have about
complete. For a copy of the form, person to serve as your Authorized
BMC HealthNet Plan’s or Beacon
call the Plan’s Member services Representative before our time-
Health Strategies’ (Behavioral
department or Beacon Health frame for resolving your Grievance
Health manager) operations. An
Strategies (for Behavioral Health). expires. If this happens, we will
Inquiry does not address your
The phone numbers are at the send you a Grievance dismissal
dissatisfaction with the Plan or
bottom of the page. notification.
Beacon Health Strategies (see
“What is a Grievance?” below). What is a Grievance?
We will resolve your Inquiries You or your Authorized
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
22
How to file a Grievance a service requested by your
You, or your Authorized Appeal BMC HealthNet Plan healthcare Provider, including
Representative, may file a 1350 Main St., 13th floor the determination that the re-
Grievance in writing, over the Springfield, MA 01107 quested service is not a Cov-
telephone, or in person. If you ered Service.
want to submit a Grievance over BMC HealthNet Plan • We reduced, suspended or
the telephone, you may call: 66 West St., Suite 205 terminated a Covered Service
Pittsfield, MA 01201 that was previously authorized.
• BMC HealthNet Plan’s Mem- • We denied, in whole or in part,
ber services department at the How quickly will the Plan or payment for a Covered Service
number listed at the bottom of Beacon make a decision on due to service coverage is-
the page your Grievance? sues.
• For Grievances related to Once we receive your Grievance, • We did not make a service Au-
Behavioral Health services, call we’ll send you a written acknowl- thorization decision within the
our Behavioral Health Member edgement of receipt within one timeframe described in Section
line listed at the bottom of the business day. We’ll immediately 4.
page. begin to work on resolving your • We did not notify you of an
Grievance. We’ll send you and Internal Appeal decision within
If you, or your Authorized Repre- your Authorized Representa- the timeframe described in
sentative, want to submit a Griev- tive a written response within 30 Section 10.
ance in writing, please mail it to: calendar days from the date we • You’re unable to obtain health-
received your Grievance. care services within the time-
BMC HealthNet Plan -- frames described in Section 6
What do you do if you do not
MassHealth speak English? “Your Health Care”.
Two Copley Place, Suite 600 If you do not understand English,
Boston, MA 02116 the Plan or Beacon Health In most instances, you will receive
Attention: Member Grievances Strategies (for Behavioral Health) a notice letting you know that one
Fax: 617-897-0805 will help you with interpreter or of the actions listed above has
translation services during the occurred. However, you, or your
Grievances regarding behavioral Grievance process at no cost to Authorized Representative, may
health services can be mailed or you. If you have any questions file an Internal Appeal whenever
filed in person at: about the Grievance process, one of these actions occurs, even
please call the BMC HealthNet if you did not receive a notice from
Quality Department – Ombudsman Plan Member services department BMC HealthNet Plan or Beacon
Beacon Health Strategies, LLC or Beacon Health Strategies (for Health Strategies. Parties involved
500 unicorn Park Drive, Suite 401 Behavioral Health) at the numbers in the Internal Appeal can also
Woburn, MA 01801 below. include the legal representative of
Fax: 781-994-7636 a deceased Member’s estate.
If you want to submit a Grievance What is an Internal Appeal? Internal Appeal decisions are
to BMC HealthNet Plan in person, You, or your Authorized Appeal made by healthcare professionals
we are located at: Representative, has the right to who have the appropriate clinical
file an Internal Appeal with BMC expertise and were not involved
BMC HealthNet Plan HealthNet Plan or Beacon Health in the original action that is being
Two Copley Place, Suite 600 Strategies (for Behavioral Health appealed or, if the Internal Appeal
Boston, MA 02116 concerns) if you disagree with one has multiple levels, were not in-
of the following Adverse Actions or volved in any of the previous levels
BMC HealthNet Plan inactions: of review.
Bourne Counting House
• We denied or decided to pro- When and how to file a
One Merrills Wharf standard Internal Appeal
New Bedford, MA 02740 vide limited Authorization for
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
23
with the Plan or Beacon Attention: Member Appeals Strategies requests to extend the
We provide Members two levels of Fax: 617-897-0805 timeframe by up to five calendar
Internal Appeal review, a first level days as described below. We will
and a second level (reviewed by If you want to submit an Internal notify you, or your Authorized
a clinician not involved with your Appeal pertaining to Behavioral Representative, in writing of our
first level Internal Appeal). You, or Health services, please mail it to: decision.
your Authorized Representative,
may file a first level Internal Appeal Appeals Coordinator What do you do if you
within 30 calendar days of our Beacon Health Strategies, LLC disagree with the decision
notice to you telling you that one 500 Unicorn Park Drive, Suite 401 the Plan or Beacon reached
on your first level
of the Adverse Actions described Woburn, MA 01801
Internal Appeal?
above has occurred. However, Fax: 781-994-7636
If you disagree with the decision
if you did not receive a notice
we reach on your first level Internal
from the BMC HealthNet Plan or If you, or your Authorized Repre-
Appeal, you, or your Authorized
Beacon Health Strategies, you, or sentative, want to submit an Inter-
Representative, can either request
your Authorized Representative, nal Appeal in person, please visit
a second level review of your
may appeal within 30 calendar us at the applicable office location
Internal Appeal through us, or you
days of learning on your own above.
can skip the second level Internal
that one of the Adverse Actions
Appeal review and file an Appeal
described above occurred. Oral requests to appeal an action
directly with the Board of Hearings
are treated as Appeals (to estab-
(see “How to File a Board of
You, or your Authorized Represen- lish the earliest possible filing date
Hearing Appeal”). If you choose
tative, may file a first level Internal for the Appeal). We will confirm
to file with the Board of Hearings,
Appeal in writing, over the tele- your oral Inquiry in writing, unless
you waive the right to a second
phone, or in person. If you, or your you, your Authorized Representa-
level Internal Appeal review.
Authorized Representative, want tive, or your Provider requests an
to submit a first level Internal Ap- expedited (fast) resolution (deci-
If you decide to request a second
peal over the telephone, you may sion).
level Internal Appeal review, you,
call:
or your Authorized Representative,
Once your first level Internal Ap-
must file your request with BMC
• BMC HealthNet Plan’s Member peal is received, an Appeals &
HealthNet Plan or Beacon Health
services department at one Grievances specialist will send you
Strategies (for Behavioral Health
of the toll-free numbers at the and your Authorized Representa-
concerns) within 30 calendar days
bottom of the page. tive a written acknowledgement of
of receiving the notice of your
• Or you may call the Appeals receipt within one business day,
first level Internal Appeal denial.
department at (617) 748-6338. and will immediately begin to work
Once we receive your second
• For Appeals related to Behav- on resolving your Appeal.
level Internal Appeal request, we
ioral Health services, call our
How quickly will you receive will send you and your Authorized
Behavioral Health Member
a decision on your first level Representative a written acknowl-
line listed at the bottom of the
Internal Appeal? edgement of receipt within one
page.
unless you, or your Authorized business day. We will immediately
If you, or your Authorized Repre- Representative, file an Expedited begin to work on the second level
sentative, want to submit a first (fast) Internal Appeal, we will review of your Internal Appeal
level Internal Appeal in writing, resolve your first level Internal and will resolve your second level
please mail it to: Appeal within a total of 20 review within a total of 20 calendar
calendar days from the day days unless you, your Authorized
BMC HealthNet Plan -- we receive it unless you, your Representative, or BMC HealthNet
MassHealth Authorized Representative, BMC Plan or Beacon Health Strategies
Two Copley Place, Suite 600 HealthNet Plan or Beacon Health requests to extend the timeframe
Boston, MA 02116 by up to five calendar days as
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
24
described below. (BMC HealthNet is totally unrelated to your health possible to request a second level
Plan and Beacon Health Strate- condition. If your Provider is not Internal Appeal review through
gies cannot request an extension if involved in your request for an Ex- BMC HealthNet Plan or Beacon
we requested an extension during pedited (fast) Internal Appeal, then Health Strategies for Expedited
your first level Internal Appeal.) We we have the right to determine (fast) Internal Appeals.
will notify you, and your Authorized whether or not to process the Ap-
Representative, in writing of our peal as an Expedited (fast) Internal Can Internal Appeal
decision. If you disagree with the Appeal. timeframes be extended?
decision, you, or your Authorized You, or your Authorized
Representative, can file an Appeal If your request does not qualify for Representative, may request
with the Board of Hearings (see an Expedited (fast) Internal Appeal, to extend the timeframes for
“How to File a Board of Hearing we will notify you and your Autho- resolving standard Internal
Appeal”). rized Representative, in writing, Appeals by up to five calendar
of this decision and process your days for each level of Internal
What is an Expedited (fast) Internal Appeal within the standard Appeal. We may request to
Internal Appeal? 20 calendar-day timeframe. You, extend the timeframes for
BMC HealthNet Plan and Beacon or your Authorized Representa- resolving either your first level
Health Strategies (for Behavioral tive, have the right to file a Griev- or second level Internal Appeal
Health concerns) provide Members ance following the procedures by five calendar days. You, your
with one level of Expedited (fast) described above if you disagree Authorized Representative, BMC
Internal Appeal review. You, your with this decision not to treat your HealthNet Plan or Beacon Health
Authorized Representative, or your Internal Appeal as an Expedited Strategies may request to extend
healthcare Provider can request (fast) Internal Appeal (see “How to the timeframes for resolving
that your Internal Appeal be File a Grievance”). Expedited (fast) Internal Appeals
expedited (processed fast) if you by up to 14 calendar days.
or your healthcare Provider feel Neither BMC HealthNet Plan nor Whenever we choose to extend a
that taking the 20 calendar-day Beacon Health Strategies will take timeframe, we will send you, and
timeframe for a standard Internal disciplinary action against a Pro- your Authorized Representative,
Appeal resolution could seriously vider who requests an Expedited a notice of this decision. If you
jeopardize your life, health or your (fast) Internal Appeal or supports a disagree with the decision, you, or
ability to get, maintain or regain Member’s Expedited (fast) Internal your Authorized Representative,
maximum function. Appeal request. may file a Grievance following the
procedures described above (see
You, or your Authorized Repre- If your Appeal is expedited (fast), it “How to File a Grievance”).
sentative, may request an Expe- is decided within 72 hours unless
dited (fast) Internal Appeal from the timeframes are extended as
BMC HealthNet Plan or Beacon described below. We will notify Please note that we can only re-
Health Strategies (for Behavioral you, and your Authorized Repre- quest an extension if:
Health concerns). If your Pro- sentative in writing of the decision.
vider is acting as your Authorized We will also try to contact you be • The extension is in your best
Representative, or if your Provider telephone to tell you about the interest.
supports the request filed by you decision. • We need additional information
or your Authorized Representative, that we believe, if received, will
in most cases we will honor the If you, or your Authorized Repre- lead to approval of your request.
request that your Internal Appeal sentative, disagree with the deci- • Such outstanding information
be treated as an Expedited (fast) sion that we reach with your Ex- is reasonably expected to be
Internal Appeal. We may refuse pedited (fast) Internal Appeal, you received within the five or 14
your Provider’s request to expedite can file an Appeal with the Board calendar-days extension time-
(process fast) your Expedited (fast) of Hearings (see “How to File a frame.
Internal Appeal request only if it Board of Hearing Appeal”). It is not
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
25
When can the Plan or Beacon you, or your Authorized • Indicate in your request that
dismiss your Internal Appeal? Representative, have the right to you want to continue to get
We may dismiss your Internal dispute our Appeal dismissal and these services.
Appeal if: request that we continue with your
Appeal. To do so, you, or your Your rights during the
• Someone else files an Internal Authorized Representative, must Internal Appeal process
Appeal on your behalf and we submit a letter to BMC HealthNet We will provide you, or your
do not receive your written Plan or Beacon Health Strategies Authorized Representative, a
Authorization for that person (for Behavioral Health concerns) reasonable opportunity to present
to serve as your Authorized requesting reconsideration of the evidence and allegations of fact
Representative before the dismissal within 10 calendar days or law, in person and in writing,
timeframe for resolving your In- of the Internal Appeal dismissal as well as allow you, or your
ternal Appeal expires. A written notice. Authorized Representative, to
Authorization is not required We will review your request for access your files before as well as
for Expedited Appeals; OR reconsideration of dismissal and during the Internal Appeal process.
• You, or your Authorized Rep- notify you and your Authorized
resentative, filed the Standard Representative of our decision. If you do not understand English,
or Expedited (fast) Internal we will help you with interpreter
Appeal more than 30 calendar Continuing Services during or translation services during the
days after the notice from BMC your Internal Appeal Internal Appeal process at no cost
HealthNet Plan or Beacon If your Internal Appeal involves a to you.
Health Strategies telling you decision by us to modify a previ-
that you had a right to Ap- ously authorized service, including What if we do not resolve
peal (or, if you did not receive a decision to reduce, suspend, your Standard/Expedited
or terminate a service, you can Internal Appeal within the
such a notice, more than 30
choose to continue receiving the required timeframes?
calendar days after learning on
requested services from BMC If we do not resolve your (first or
your own about our actions or
HealthNet Plan or Beacon Health second level) standard Internal
inactions that give you a right
Strategies during the Internal Appeal within 20 calendar days
to Appeal); OR
Appeal process. But if you lose (or within five additional calendar
• You, or your Authorized Rep-
the Appeal, you may have to pay days if we take an extension), you,
resentative, filed the second
back the cost of these services. or your Authorized Representative,
level review of your Internal
If you want to receive Continuing can file your Appeal with the Board
Appeal more than 30 calendar
Services, you or your Authorized of Hearings (see “How to File a
days after the notice from BMC
Representative must: Board of Hearings Appeal” below).
HealthNet Plan or Beacon
Health Strategies telling you How to file a Board of
about our decision to uphold • Submit your (Standard first Hearings Appeal
your first level Internal Appeal. level or Expedited (fast)) Inter- You, or your Authorized
nal Appeal request within 10 Representative, have the right to
We will send you and your Autho- calendar days from the date of request a hearing before a hearing
rized Representative an Internal our notice that it has decided officer at the Executive Office
Appeal dismissal notification. to modify a previously autho- of Health and Human Services,
rized service or submit your Office of Medicaid’s, Board of
Can an Internal Appeal second level standard Inter- Hearings. You may file a hearing
dismissal be disputed? nal Appeal request within 10 request within 30 calendar days of
If you, or your Authorized calendar days from the date of the Plan’s or Beacon’s notification
Representative, believe that you our notice that it decided your of a standard or Expedited (fast)
indeed requested your Internal first level Internal Appeal; and Internal Appeal decision if you, or
Appeal within 30 calendar days • your Authorized Representative,
and have supporting evidence, • disagree with the decision that we
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
26
reach when we resolve your: decision to reduce, suspend, the Board of Hearings Appeal
or terminate a service, you can process, please call the BMC
• first level standard Internal choose to continue receiving the HealthNet Plan or Beacon Health
Appeal and you choose to skip requested services during the Strategies (for Behavioral Health
our second level Internal Ap- Board of Hearings Appeal process. concerns) Member services de-
peal; But if you lose the Appeal, you partment at the numbers listed at
• second level standard Internal may have to pay back the cost the bottom of the page.
Appeal; OR of these services. If you want You also have the right to voice
• Expedited (Fast) Internal Ap- to receive Continuing Services any concerns to MassHealth at
peal. during the Board of Hearings any time. You may call a cus-
process, you, or your Authorized tomer service representative at
We will include the request for fair Representative, must submit your the MassHealth customer service
hearing form and other instructive Board of Hearings Appeal request center at the number at the bot-
material that you, or your Autho- within ten (10) calendar days from tom of the page.
rized Representative, need to the date of the decision resolving
request a fair hearing in the written your Internal Appeal. If you do not
decision resolving your Internal want to keep getting the requested
Appeal. We will also assist you, or services during your Board of SECTION 11
your Authorized Representative, in Hearing Appeal, you must check
completing the application. Box A in Section III of the fair
Notice of Privacy
hearing form. Practices
How do you get an Expedited
(fast) fair hearing at the What rights do you have This Notice describes how health
Board of Hearings? during the Board of Hearings information about you may be
If you, or your Authorized Appeal process? used and communicated, and how
Representative, are appealing a BMC HealthNet Plan and Beacon you can get this information.
decision resolving an Expedited Health Strategies (for Behavioral
(fast) Internal Appeal and you, or Health concerns) will allow you, or Please review this Notice of Pri-
your Authorized Representative, your Authorized Representative, to vacy Practices carefully. If you
also want the Board of Hearings access your files during the Board have any questions, please call
to handle your request as an of Hearings Appeal process. the BMC HealthNet Plan Member
Expedited (fast) fair hearing, you, services department.
At the hearing, you may represent
or your Authorized Representative, yourself or be accompanied by This Notice of Privacy Practices,
must submit the fair hearing request an Authorized Representative or which was effective April 14,
within 20 calendar days from the an attorney, acting as your Autho- 2003, describes how we may use
date of the decision. If you, or your rized Representative, at your own and communicate your Protected
Authorized Representative, file expense. Parties may also include Health Information (PHI) to carry
between days 21 and 30 calendar the legal representative of a de- out treatment, payment or health-
days, the Board of Hearings will ceased Member’s estate. care administration, and for other
process your Appeal within the purposes that are permitted or
standard Board of Hearings Appeal We will implement the Board of required by law. It also describes
timeframe. Hearings Appeal decision immedi- your rights to access and control
ately. your Protected Health Informa-
Continuing Services during If you do not understand English tion. Protected Health Information
your fair hearing at the Board and/or are hearing or sight im- or PHI is information about you,
of Hearings paired, the Board of Hearings will including demographic informa-
If your Board of Hearings Appeal make sure that an interpreter and/ tion, that may identify you and that
involves a decision by BMC or assisting device is available for relates to your health condition
HealthNet Plan or Beacon Health you at the hearing. and/or related healthcare services.
Strategies to modify a previously
authorized service, including a If you have any questions about
By law, we are required to:
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
27
We will also record the actions ment, payment and operations.
• Maintain the privacy and con- they took and their observations. Required By Law: We will com-
fidentiality of your Protected That way, the healthcare team municate PHI about you when we
Health Information will know how you responded to are required to do so by federal,
• Give you this Notice of Privacy treatment. state or local law. This includes
Practices For Payment: We may use and workers’ compensation laws. We
• Follow the practices in this communicate PHI about you so may release PHI about you for
Notice that others may bill and receive workers’ compensation or similar
payment for the treatment and programs. These programs pro-
We use physical, electronic and services that you received. vide benefits for work-related
procedural safeguards to protect injuries or illness.
your privacy. Even when disclo- For Health Care Administration:
sure of PHI is allowed, we only use We may use and communicate Public Health and Safety: We
and disclose PHI to the minimum PHI about you to support our nor- may communicate your PHI for
amount necessary for the permit- mal business activities. For exam- public health reasons, for example
ted purpose. ple, we may use your information to prevent or control disease and
to review and improve the services to report births and deaths.
Other than the situations men- you receive, communicate infor-
tioned in this Notice of Privacy Abuse or Neglect: We may com-
mation to personnel for review municate your PHI to a govern-
Practices, we cannot use or share and learning purposes, and com-
your Protected Health Information ment authority if we reasonably
municate your Protected Health believe you are a victim of abuse
without your written permission, Information to other organizations
and you may cancel your permis- or neglect. We will only communi-
that help us with our business cate this type of information to the
sion any time by sending us a activities.
written notice. extent required by law, if you agree
For Personal Communications: to the disclosure, or if the dis-
We reserve the right to change this We may contact you to provide closure is allowed by law and we
Notice of Privacy Practices and to appointment or refill reminders, or believe it is necessary to prevent
make the revised notice effective information about possible treat- serious harm to you or someone
for any of your current or future ment options or alternatives and else.
Protected Health Information. You other health-related benefits, or
are entitled to a copy of the Notice Health Oversight Activities: We
services that may be of interest to may communicate PHI to a health
of Privacy Practices currently in you.
effect. oversight agency for activities au-
Fundraising Activities: We may thorized by law, including audits,
We May Use and use PHI about you in an effort to investigations, inspections, and li-
Communicate Protected raise money. If you do not want censing purposes. We may have to
Health Information (PHI) us to contact you for fundraising do this for certain state and federal
about You efforts, you may opt out by no- agencies to monitor the healthcare
For Treatment: We may tifying us, in writing, with a letter system, government programs and
communicate PHI about you to addressed to the BMC HealthNet compliance with civil rights laws.
doctors, nurses, technicians, Plan Privacy Officer. Lawsuits and Disputes: If you
office staff or other personnel
are involved in a lawsuit or dis-
who are involved in taking care of Privacy Officer pute, we may communicate PHI
you and need the information to BMC HealthNet Plan about you in response to a court
provide you with health care. For Two Copley Place, Suite 600 or administrative order. We may
example, if you are being treated Boston, MA 02116 also communicate PHI about you
for a back injury, we may share
because of a subpoena or other
information with your Primary Care In some limited situations, the law lawful process, subject to all ap-
Provider, the back Specialist and allows or requires us to use or plicable legal requirements.
the physical therapist so they can communicate your health informa-
determine the proper care for you. tion for purposes beyond treat- Law Enforcement: We may
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
28
release your PHI upon request approval process. This process Food and Drug Administration
by a law enforcement official in requires an evaluation of the pro- (FDA): We may communicate to
response to a valid court order, posed research project and its use the FDA, or persons under the
subpoena or similar process. of PHI, and balances the research jurisdiction of the FDA, your PHI
needs with our Members’ need for as it relates to adverse events with
Military, Veterans, National
privacy. Before we use or disclose medications, foods, supplements
Security and Intelligence: If If
PHI for research, the project will and other products and market-
you are a member of the armed
have been approved through this ing information to support product
forces, we may release your PHI
special approval process. How- recalls, repairs or replacement.
as required by military command
authorities. We may be required by ever, this special approval process
other government authorities to re- is not required when we allow Your rights regarding
lease your PHI for national security researchers who are preparing a Protected Health Information
activities. research project to look at infor- about you
mation about patients with specific Right to Access and Copy: You
Family and Friends: We may medical needs, so long as the PHI have the right to inspect and
communicate PHI to a member they review does not leave BMC receive a copy of PHI that may
of your family, a relative, a close HealthNet Plan be used to make decisions about
friend, or any other person you
your care. usually, this includes
identify who is directly involved in Coroners, Medical Examiners and
medical and billing records.
your health care or payment relat- Funeral Directors: We may com-
municate PHI to coroners, medical Psychotherapy notes may not be
ed to your care. For example, we
inspected or copied. To inspect
may communicate PHI to a friend examiners and funeral directors
or receive a copy of your records,
who brings you into an Emergency for identification purposes and as
needed to help them carry out their you must submit a written request
room.
duties consistent with applicable to the BMC HealthNet Plan Privacy
Serious Threat to Health or law. Officer.
Safety: We may use and commu-
Privacy Officer
nicate PHI about you when neces- Organ and Tissue Donation: If
you are an organ donor, we may BMC HealthNet Plan
sary to prevent a serious threat
communicate your PHI to organi- Two Copley Place, Suite 600
to your health and safety or the
zations that handle organ procure- Boston, MA 02116
health and safety of the public or
another person. ment, banking or transplantation We may deny your request to
for purposes of tissue donation inspect or receive a copy in cer-
Disaster Relief: We may com- and transplant. tain very limited circumstances. If
municate PHI to an authorized
you are denied access to PHI, we
public or private entity for disaster Correctional Facilities: If you are or
become an inmate in a correctional will notify you in writing, and you
relief purposes. For example, we
facility, we may communicate your may request that the denial be
might communicate your PHI to
reviewed. If you request a review,
help notify family members of your PHI to the correctional facility or its
agents, as necessary, for your health a BMC HealthNet Plan attorney
location or general condition.
and the health and safety of other or other qualified BMC Health-
Research: under certain circum- individuals. Net Plan employee who was not
stances, we may use and disclose involved in the original decision
your PHI for research purposes. Business Associates: Some of our
to deny your request to inspect
For example, a research project services and products are provided
or receive a copy of your records
may involve comparing the health through contracts with business as- will re-evaluate your request, and
and recovery of all Members sociates, and we may communicate
respond to you in writing.
who received a particular type of your PHI to our business associates
so that they may perform the job we Right to Amend: If you believe
Care Management to those who
have asked them to do. To protect that PHI we have about you is
received another for the same
incorrect or incomplete, you may
condition. Most research projects, your PHI, however, we require the
business associates to properly ask us to amend the information.
however, are subject to a special
safeguard your PHI. You have the right to request an
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
29
amendment for as long as the your request, you must tell us: (1) Authorizations for Other Uses
information is kept by or for BMC what information you want to limit; and Disclosures of PHI
HealthNet Plan. You must request (2) whether you want to limit the uses or disclosures of your PHI
an amendment, in writing, to the Plan’s use and/or disclosure of the for other purposes or activities
BMC HealthNet Plan Privacy Of- information; (3) to whom you want not listed above will be made only
ficer and include a reason that the limits to apply (for example, with your written authorization
supports your request. In certain disclosures to your spouse); and (permission). If you provide us
cases, we may deny your request (4) your contact address. with written authorization to use
for amendment. or disclose your PHI, you may
Right to Request Confidential
revoke your authorization in
Right to an Accounting of Dis- Communication: You have the
writing at any time. If you revoke
closures: You have the right to right to request that we com-
your authorization, we will no
request an “accounting of disclo- municate with you about medical
longer use or disclose your PHI
sures.” This is a list of the entities matters in a certain way or at a
for the reasons covered by your
or persons (other than yourself) to certain location. For example, you
written authorization. However,
whom the Plan has disclosed your can ask that we only contact you
we are unable to take back any
health information without your by telephone at work or that we
disclosures that have already been
written authorization. The account- only contact you by mail at home.
made with your authorization.
ing would not include disclosures Your request must specify how or
for treatment, payment, health where you wish to be contacted. Compliance with laws
care operations, and certain other We will accommodate all reason- If more than one law applies to this
disclosures exempted by law. To able requests. To request confi- Notice of Privacy Practices, we will
obtain an accounting, you must dential communication, you must follow the more stringent law.
submit your request, in writing, to complete and submit a Request
the BMC HealthNet Plan Privacy for Confidential Communication Complaints
Officer. It must state a time period, Form to the BMC HealthNet Plan If you believe your privacy rights
which may not be longer than six Privacy Officer. You can get a form have been violated, you may file a
years and may not include dates by calling our Member services complaint with our office or with
before April 14, 2003. department. the Secretary of the Department of
Right to Request Restrictions: Right to Obtain a Paper Copy Health and Human Services.
You have the right to request a or Electronic Version of This To file a complaint with our office,
restriction or limitation on the PHI Notice: You have the right to a contact:
we use or disclose about you for paper copy of this Notice of Pri-
treatment, payment or health care vacy Practices. You may ask us to Privacy Officer
operations. You also have the right give you a copy of this Notice of BMC HealthNet Plan
to request a limit on the PHI we Privacy Practices at any time by Two Copley Place, Suite 600
disclose about you to someone contacting the Member Services Boston, MA 02116
who is involved in your care or the Department. You may also obtain
payment for your care, such as a an electronic version of this Notice You will not be penalized for filing
family member or friend. We are of Privacy Practices on our Web a complaint.
not required to agree with your re- site, bmchp.org.
quest. If we do agree, we will com- Assistance in Preparing Written You may file a complaint under the
ply with your request unless the Documents: BMC HealthNet Plan HIPAA Privacy Rule with the Office
information is needed to provide will provide you with assistance of Civil Rights (OCR). Complaints
you with emergency treatment. in preparing any of the requests must be filed in writing within 180
BMC HealthNet Plan will notify you explained in this Notice of Privacy days of an alleged violation, unless
in writing whether we agree or not Practices that must be submitted OCR extends this time require-
with your request. Please submit in writing. There will be no cost to ment for good cause. You can
your request in writing to the BMC you for this. find additional information at the
HealthNet Plan Privacy Officer. In following Web site: http:www.hhs.
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
30
gov/ocr/hipaa, including the Health Health Care Proxy If you become ineligible for
Information Privacy Complaint A Health Care Proxy is a document MassHealth coverage, MassHealth
Form. You can file HIPAA Privacy that lets you name someone will disenroll you from BMC
complaints via email to OCRCom- to make decisions about your HealthNet Plan. You will no longer
plaint@hhs.gov or by mail to the medical care – including decisions be eligible for coverage by BMC
following OCR about life support – if you can no HealthNet Plan as of the date of
longer speak for yourself. This your MassHealth Disenrollment.
Regional Office: person would carry out the wishes You may automatically be re-
Office for Civil Rights U.S. De- you described in your “living will.” enrolled in BMC HealthNet Plan
partment of Health & Human This person becomes known if you become eligible again for
Services JFK Federal Building as your Health Care “Agent” or MassHealth within 6 months, as
Room 1875 “Proxy.” determined by MassHealth.
Boston, MA 02203 Once you set up your Advance
Directives, you can change your Disenrollment for cause
If you need help filing a complaint mind at any time. BMC HealthNet Plan will not
you can call OCR’s toll free num- request to disenroll a Member
ber 1-800-368-1019. To get the Health Care Proxy and due to an adverse change in
Living Will forms, you can visit a Member’s health status or
BMC HealthNet Plan’s Web site at
SECTION 12
because of a Member’s utilization
bmchp.org. BMC HealthNet Plan of medical services, diminished
can also mail the forms to you. mental capacity or uncooperative
Call the Plan’s Member services
Advance Directives department.
or disruptive behavior resulting
from his or her special needs.
Advance Directives are legal docu-
ments that allow you to share your
SECTION 13
There may be instances where
decisions about end-of-life care
BMC HealthNet Plan may submit
ahead of time. Advance Directives
a written request to MassHealth
provide a way for you to communi-
cate your wishes to family, friends Disenrollment to disenroll a Member from the
Plan. MassHealth will determine
and health care professionals, and
Voluntary Disenrollment when and if BMC HealthNet Plan’s
to avoid confusion. An Advance
You may end your coverage with request will be granted. If you are
Directive allows you to legally
BMC HealthNet Plan at any time. disenrolled from BMC HealthNet
express in writing your health care
To disenroll from BMC HealthNet Plan, MassHealth will send you
wishes in case you can’t do so if
Plan, call MassHealth customer written notification of Disenroll-
you are seriously sick or injured.
service. Voluntary Disenrollments ment. You also will be contacted
There are two kinds of Advance
are usually effective one business by MassHealth to choose another
Directives: a Living Will and a
day after BMC HealthNet Plan health plan.
Health Care Proxy.
gets the request from MassHealth.
BMC HealthNet Plan will continue
SECTION 14
Living Will
The Living Will lists medical to provide coverage for:
procedures/types of health care
• Covered Services through the
that you do, or do not want under
date of Disenrollment
Coordination of
certain circumstances if you
become seriously sick or injured. • Any custom-ordered equip- Benefits/Subrogation
An example would be if you ment approved prior to Disen-
rollment, even if not delivered You must tell us if you have any
decided that you don’t want to be
until after Disenrollment. other health insurance coverage in
kept alive using life support if you
addition to MassHealth. You must
became very ill.
Disenrollment for loss of also let us know whenever there
Eligibility are any changes in your additional
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
31
insurance coverage. The types of provides you with health care be subrogated. This means that
additional insurance you might coverage, unless the law states we may use your right to recover
have include: something different. In other money from the person(s) who
situations, such as for benefits caused the injury or from any
• Coverage from an employer’s that are not covered by BMC insurance company or other party.
group health insurance for em- HealthNet Plan, you may be able If another person or party is, or may
ployees or retirees, either for to get your care covered by an be, liable to pay for services related
yourself or your spouse insurer other than us. If you have to your illness or injury that may
• Coverage under workers’ com- additional health insurance, please have been paid for or provided by
pensation because of a job- call us at 888-257-1985 to find out us, we will subrogate and succeed
related illness or injury how payment will be handled. to all your rights to recover against
• Coverage for an accident If you have comprehensive health such person or party 100 percent
where no-fault insurance or li- insurance with another health of the value of services paid for or
ability insurance is involved plan, provided by us.
• Coverage you have through
veteran’s benefits including Medicare, you are not Claims incurred as a result of
• “Continuation coverage” that eligible for MassHealth benefits any Subrogation case should be
you have through COBRA from Managed Care organizations, submitted before any settlement.
(COBRA is a law that requires including BMC HealthNet Plan. Claims for services rendered
employers with 20 or more If you fit this category, you will before a settlement that are not
employees to let employees need to be disenrolled from BMC submitted before that settlement is
and their Dependents keep HealthNet Plan. MassHealth will reached may be denied.
their group health coverage notify you about this.
for a time after they leave their In the event another party reimburses
Motor vehicle accidents and/
group health plan under certain or work-related injury/illness any medical expense we pay for,
conditions.) If you are in a motor vehicle we will be entitled to recover from
accident, you must use all of your you 100 percent of the amount you
BMC HealthNet Plan is the payer auto insurance carrier’s medical got for such services from us. The
of last resort for payment of medi- coverage (including personal injury amount you must pay back to us
cal services involving Coordination protection (PIP) and/or medical will not be reduced by any attorney’s
of Benefits and third-party-liability payment coverage) before we will fees or incurred expenses.
or Subrogation. Please see the consider paying for any of your
following sections for more expenses. You must send to us any To enforce our Subrogation rights
information. explanation of payment or denial under this Member handbook, we
letters from an auto insurance will have the right to take legal
Coordination of Benefits action, with or without your
When you have other health carrier for us to consider paying a
Claim that your Provider sends to us. consent, against any party to
insurance coverage, we work with secure recovery of the value of
your other insurance to coordinate In the case of a work-related injury
or illness, the workers’ compensation services provided or paid for by us
your BMC HealthNet Plan benefits. for which that party is, or may be,
The way we work with the other carrier will be responsible for those
expenses first. You must send to liable. Nothing in this handbook
companies depends on your will be interpreted to limit our right
situation. This process is called us any explanation of payment or
denial letters from an auto insurance to use any remedy provided by law
Coordination of Benefits. Through to enforce its rights to Subrogation
this benefit coordination, you will carrier for us to consider paying a
Claim that your Provider sends to us. under this Member handbook.
often get your health insurance
coverage as usual through us. If We require you to follow all Prior
Subrogation Authorization requirements even
you have other health insurance,
If you are injured by the act or when third-party-liability exists.
our coverage will always be
omission of another person, your Authorization is not a guarantee of
secondary when the other plan
BMC HealthNet Plan benefits will payment.
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
32
Member cooperation
As a Member of BMC HealthNet
Plan, you agree to cooperate
SECTION 15 Beacon Health Strategies – A
partner of BMC HealthNet Plan
that manages and coordinates the
with us in exercising our rights to Glossary Behavioral Health (mental health
Subrogation and Coordination of and substance abuse) services for
Benefits. This means you must Advance Directive – A written Members and manages the Be-
complete and sign all necessary statement that tells a Provider havioral Health Provider network.
documents to help us exercise our what to do if an illness or accident
rights. This also means that you takes away the Member’s ability Behavioral Health – Mental health
must give us notice before settling to make decisions about his or her and substance abuse services
any Claim arising out of injuries health care.
you sustained by any liable party(s) BMC HealthNet Plan (the Plan)–
for which we have Adverse Action – The follow-
A managed care organization
provided coverage. You must not ing actions or inactions by BMC
providing coverage to MassHealth
do anything that might limit our HealthNet Plan or Beacon Health
(Medicaid) and Commonwealth
right to full reimbursement. These Strategies:
Care members. The Plan contracts
Subrogation and recovery provisions 1. Denying or limiting coverage of
with Providers and hospital sys-
apply, whether or not the Member a requested healthcare service;
tems throughout Massachusetts
recovering money is a minor. 2. Reducing or stopping coverage
to deliver care to Members state-
We ask that you: for a service that was previously
wide.
approved;
3. Denying payment for a service BMC HealthNet Plan Network
• Give us all information and
because it was not Medically Provider – A Provider with which
documents we request
Necessary; BMC HealthNet Plan has an agree-
• Sign any documents we think
4. Not responding to an ment to offer Covered Services to
are necessary to protect our
Authorization request in a timely Members.
rights
• Promptly assign us any money manner; Board of Hearings – the Board
gotten for services for which 5. Not being able to get health of Hearings within the Executive
we’ve provided or paid care within required timeframes; Office of Health and Human Ser-
• Promptly notify us of any pos- and vices’ Office of Medicaid.
sible Subrogation or benefit 6. Not resolving an Appeal request Board of Hearings (BOH) Appeal
coordination potential within required timeframes. – A written request to the BOH,
Appeal – A request by a MassHealth made by a Member or Authorized
You also must agree to do nothing Member/Authorized Representative Representative to review the cor-
to prejudice or interfere with our to BMC HealthNet Plan or Beacon rectness of a Final Internal Appeal
rights to Subrogation or benefit Health Strategies or the Office of decision by BMC HealthNet Plan
coordination. If you are not willing Medicaid’s Board of Hearings for or Beacon Health Strategies.
to help us, you will be liable to us review of an action or inaction by the
Plan. Care Management – A program
for any expenses we may incur,
offered by BMC HealthNet Plan
including reasonable attorneys’
Authorization – A special approval and Beacon Health Strategies (for
fees, in enforcing our rights under
by BMC HealthNet Plan or Beacon Behavioral Health) to our Mem-
this plan. Nothing in this Member
Health Strategies for payment of bers who are most in need of
handbook may be interpreted to
certain Covered Services that is done assistance with managing multiple
limit our right to use any means
prior to receiving the services. situations, services, and/or Provid-
provided by law to enforce our
ers at one time. The situations may
rights to Subrogation or benefit
Authorized Representative – some- be medical, behavioral, social and/
coordination under this plan.
one authorized by you in writing to or environmental in nature. The
act on your behalf regarding a spe- services may be preventive, well-
cific Grievance or Appeal. ness, disease, treatment or hous-
ing related. The Providers may
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
33
include your or a family member’s Clinical Practice Guidelines– individual becomes a Member
PCP, Specialists, other health care Standards for care that BMC of BMC HealthNet Plan and is
Providers – such as home health HealthNet Plan and Beacon Health eligible for Covered Services.
care agencies – as well as staff Strategies use with its Provider Generally one business day
from state agencies. Network to make sure that Mem- after BMC HealthNet Plan re-
The BMC HealthNet Plan Care bers are getting the best care. ceives notification of Enrollment
from Mass Health.
Management Program consists of
four distinct program categories Community Service Agency Eligibility – MassHealth enrollees
that provide services for our Mem- (CSA) – There are 32 CSA’s across qualified to receive MassHealth
bers. The four program categories the state offering care coordina- health coverage.
are Care Management Education tion services to MassHealth eli- Emergency – A medical condi-
and Wellness, Care Management gible youth with serious emotional tion, whether physical or mental,
Health Care Coordination, Care disturbance (SED) and their fami- manifesting itself by symptoms
Management Select, and Intensive lies/caregivers. of sufficient severity, including
Clinical Management (ICM). severe pain, that, in the absence
Continuity of Care – The process of prompt medical attention,
Child Adolescent Needs and that ensures that Members do not could reasonably be expected by
Strengths (CANS) Tool – A tool have disruptions in their medical a prudent lay person who pos-
that provides a standardized way or Behavioral Health care due to sesses an average knowledge of
for Behavioral Health Providers to switching health plans or Provider health and medicine to result in
placing the health of an Enrollee or
organize information gathered dur- changes. another person or, in the case of
ing Behavioral Health clinical as- a pregnant woman, the health of
sessments for Members under the Continuing Services – The pro- the woman or her unborn child, in
age 21 and during the discharge cess of continuing to receive cer- serious jeopardy, serious impair-
planning process from inpatient tain services from BMC HealthNet ment to bodily function, or serious
psychiatric hospitalizations and Plan or Beacon Health Strategies dysfunction of any body organ or
community based acute treatment during an Appeal. part; or, with respect to a pregnant
services. woman, as further defined in sec-
Coordination of Benefits – The tion 1867(e)(1)(B) of the Social Se-
process that BMC HealthNet Plan curity Act, 42 u.S.C. § 1395dd(e)
Children’s Behavioral Health uses to work with any other health (1)(B).
Initiative (CBHI) – The Children’s insurers Members may have. Enrollment – The process by
Behavioral Health Initiative is an which BMC HealthNet Plan regis-
inter-agency initiative of the Com- Co-payment – Payments made by ters individuals for membership.
monwealth of Massachusetts’ Members at the time of care.
Executive Office of Health and Hu- EPSDT (Early and Periodic
man Services whose mission is to Covered Services – The services Screening, Diagnostic and Treat-
strengthen, expand and integrate and supplies covered by BMC ment) Services – Preventive care
Massachusetts state services into HealthNet Plan and MassHealth and treatment services provided
a comprehensive, community- described in the Covered Services by a Primary Care Provider on a
list in this Member handbook. periodic schedule. The schedule is
based system of care, to ensure
determined by the age when each
that families and their children with Dependent – A person who gets procedure is to be provided and
significant behavioral, emotional health coverage through another includes a complete assessment
and mental health needs obtain the person, such as a spouse, parent, (e.g. health screens), service coor-
services necessary for success in or grandparent. dination, crisis intervention and in
home, school and community. home services.
Disenrollment – The process by
Claim – A bill from a Provider that which a Member’s BMC HealthNet Expedited (fast) Internal Appeal
describes the services that have Plan coverage ends. – A 72-hour Appeal process.
been provided to a Member.
Effective Date – An Effective Family Planning Services –
Date is the date on which an Services directly related to pre-
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
34
venting conception. They include (1) persons who have been identi-
birth control counseling, education Intensive Clinical Management fied by the Department of Mental
about family planning, examination (ICM) – A Care Management pro- Health (DMH) as getting services
and treatment, laboratory exami- gram provided by Beacon Health or as being on a waiting list to
nations and tests, medically ap- Strategies. ICM care managers get services from the DMH, are
proved methods and procedures, through collaboration with Mem- “long-term unemployed,” and
pharmacy supplies and devices,
bers and their treatment Providers,
sterilization, including tubal ligation have income at or below 100%
and vasectomy. (Abortion is not a work to ensure the coordination of the federal poverty level; or (2)
Family Planning Service.) and optimization of care; assess- persons who are getting Emer-
ment, care planning, discharge gency Aid to the Elderly, Disabled
Final Internal Appeal – The planning and mobilization of and Children (EAEDC) through the
second-level review of an Inter- resources to Members who are Department of Transitional Assis-
nal Appeal or, for a Member, or a dealing with Behavioral Health or tance; or (3) persons who are re-
Member’s Appeal Representative, psychosocial conditions, some- ceiving MassHealth Basic pending
who waives the second-level Inter- times along with in addition to an appeal to the Board of Hearings
nal Appeal, the first-level review of medical concerns. of EOHHS’s decision that they are
an Internal Appeal. no longer eligible for MassHealth.
Internal Appeal – A verbal or writ-
Fraud – An intentional decep- ten request for BMC HealthNet MassHealth CommonHealth – A
tion or misrepresentation made Plan or Beacon Health Strategies MassHealth benefit plan that offers
by a person or corporation with to review an Adverse Action. health benefits to certain disabled
the knowledge that the deception children under age 18, and certain
could result in some unauthor- Living Will – A document that lists working or non-working disabled
ized benefit under the MassHealth medical procedures that you do, or adults between the ages of 18 and 64.
program to himself or herself, the do not, want under certain circum-
corporation or some other person. stances if you become seriously MassHealth Essential – A
An example of Fraud is Members sick or injured. MassHealth benefit plan that offers
lending their BMC HealthNet Plan health benefits to certain individu-
ID card to others so they can get Managed Care – A system of als or Members of a couple over
health care or pharmacy services. health care delivery that is provid- the age of 18 and under the age of
Grievance – A statement by a ed and coordinated by a Primary 65 who are long-term unemployed
Member of dissatisfaction with Care Provider (PCP). The goal is and who do not meet the eligibility
care or services received. a system that delivers value by criteria for MassHealth Basic.
Health Care Agent or Proxy – The providing access to quality, cost
individual responsible for making effective health care. MassHealth Family Assistance
healthcare decisions for a person – A MassHealth benefit plan that
in the event that person is unable MassHealth – A health care pro- offers health benefits to certain eli-
to make decisions for him/her self. gram operated by the Massachu- gible Members, including families
setts Executive Office of Health and children under the age of 18.
Health Risk Assessment – A and Human Services. The national
questionnaire about a Member’s health insurance program called MassHealth Standard – A
current health situation that helps Medicaid is called MassHealth in MassHealth benefit plan that offers
BMC HealthNet Plan and Beacon Massachusetts. BMC HealthNet a full range of health benefits to
Health Strategies provide the right Plan covers MassHealth Members certain eligible Members, includ-
care to Members. under the Standard, Common- ing families, children under age
Health, Basic, Family Assistance 18, pregnant women, and disabled
Inpatient – Services requiring and Essential Plans. individuals under age 65.
at least one overnight stay and
generally applies to care in facili- MassHealth Basic – A Medicare Part D – As a BMC
ties such as hospitals and skilled MassHealth benefit plan that HealthNet Plan MassHealth Mem-
nursing facilities. offers health benefits to certain ber with Medicare coverage, your
individuals over the age of 18 and prescription drug benefit may be
Inquiry – Any question a Member under the age of 65 who qualify covered by a Medicare Prescrip-
has about BMC HealthNet Plan’s under EOHHS’s MassHealth Basic tion Drug Coverage (Part D) plan.
or Beacon Health Strategies’ op- eligibility criteria which includes Most of your prescription drugs
erations.
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
35
will be covered under your Medi- received following an Emergency Provider if those services are cov-
care Part D benefit. situation. ered benefits and within the scope
of the Provider’s license.
Medically Necessary Services PPHSD – Preventive Pediatric
– those services 1) which are Healthcare Screening and Di- Provider Directory – An online
reasonably calculated to prevent, agnosis. These are preventive search tool or printed booklet
diagnose, prevent the worsening care and treatment services that containing a list of BMC HealthNet
of, alleviate, correct or cure condi- BMC HealthNet Plan covers for Plan’s affiliated medical facilities
tions in the Member that endanger MassHealth Members under the and professionals, including Pri-
life, cause suffering or pain, cause age of 21 who are part of the Ba- mary Care Providers, Specialists
physical deformity or malfunction, sic, Family Assistance or Essential and Behavioral Health Providers.
threaten to cause or to aggravate plans.
a disability, or result in illness or Quality Improvement – A pro-
infirmity; and 2) for which there is Primary Care Provider (PCP) – A gram designed to identify ways
no comparable medical service or doctor or nurse practitioner se- to improve the quality of care that
site of service available or suitable lected by the Member or assigned Members receive.
for the Member requesting the by BMC HealthNet Plan to pro-
service that is more conservative vide and coordinate a Member’s Referral – A recommendation to
or less costly; and 3) are of a qual- healthcare needs. Other health- receive care from a Provider.
ity that meets generally accepted care Providers, such as registered
standards of medical care. nurses, physician’s assistant or Region – MassHealth divides the
nurse midwives, acting on behalf state into five geographic regions.
Member – Any person enrolled of and in consultation with a PCP, Your region is the part of the state
in BMC HealthNet Plan and may provide Primary Care Ser- that you live in and also where
MassHealth. vices. you should choose a Primary Care
Provider.
Prior Authorization – Approval
Member ID Card – The card given by BMC HealthNet Plan or
that identifies an individual as a Beacon Health Strategies for cer-
Member of BMC HealthNet Plan. Routine Care – Care that is not
tain Provider visits or health care Emergency or urgent Care. Exam-
The Member ID Card includes services in order for these to be
the Member’s identification num- ples of Routine Care are physical
covered. This approval must be exams and well-child care visits.
ber and information about the obtained by your Provider before
Member’s coverage. Members you go to certain Providers or
will also receive an ID Card from Second Opinion – The process by
before you get certain healthcare which a Member seeks an evalua-
MassHealth. services.
Both ID Cards must be shown to tion by another Provider to confirm
Providers before receiving care. the diagnosis and treatment plan
Protected Health Information of their primary Provider.
(PHI) – Information about you that
Network – The group of Provid- may identify you and that relates
ers contracted by BMC HealthNet Service Area – The geographi-
to your health condition and/or cal area approved by MassHealth
Plan to provide health care ser- related healthcare services.
vices to Members. within which BMC HealthNet Plan
has developed a Network of Pro-
Provider – A healthcare profes- viders to provide adequate access
Notice of Privacy Practices –
sional or facility licensed as re- to Covered Services.
A detailed statement about how
Member health information can quired by state law. Providers
and cannot be used. include doctors, hospitals, labora- Specialist – A Provider who is
tories, pharmacies, skilled nursing trained and certified by the state of
Nurse Advice Line – A 24 hour/7 facilities, nurse practitioners, regis- Massachusetts to provide spe-
day a week telephone line that tered nurses, psychiatrists, social cialty services. Examples include
BMC HealthNet Plan Members workers, licensed mental health cardiologists, obstetricians and
can call to speak to a trained dermatologists.
counselors, clinical Specialists in
nurse about health questions. psychiatric and mental health nurs- Subrogation – The procedure
ing, and others. BMC HealthNet under which BMC HealthNet Plan
Post Stabilization care – Care
Plan will only cover services of a can recover the full or partial cost
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
36
of benefits paid from a third per-
son or entity, such as an insurer.
Urgent Care – Medical care re-
quired quickly to prevent a wors-
ening of health due to symptoms
that a prudent lay person would
believe are not an Emergency but
do require medical attention. ur-
gent Care does not include Rou-
tine Care.
Utilization Management – The
process by which BMC HealthNet
Plan reviews the clinical necessity,
appropriateness, or efficiency of
covered services, procedures, or
settings.
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
37
SECTION 16
INDEX
Advance Directives ................................................ 31 Eligibility Review Verification (ERV) .....................................1
Appeal representative ........................................... 23 Emergencies .........................................................................9
Appeals ...................................................................23 Emergency room ................................................................. 9
Asthma ..................................................................... 2 Extras .................................................................................... 2
Becoming a Member .............................................. 1 Family Planning Services .................................................... 7
Behavioral Health .................................................... 6 Family practice doctors ...................................................... 8
(mental health and substance abuse) Fraud (reporting) ................................................................. 22
Benefits .......................... see Covered Services List Free for our Members ......................................................... 8
Bicycle helmets ....................................................... 2 General practice doctors .................................................... 8
Bills ............................................................................ 7 Generic medications ......................................................... 15
Board of Hearing Appeal ...................................... 27 Grievances ..........................................................................22
Breast pumps .......................................................... 2 Growth problems (children) ............................................... 18
BMC HealthNet Plan ............................................... 1 Gynecologist ........................................................................ 9
Car seats .................................................................. 2 Health care ........................................................................... 1
Care Management ................................................ 18 Health Risk Assessment ....................................................11
Changing your PCP ................................................ 9 High blood pressure ............................................................ 2
Chronic disease management ............................. 19 ID Card ................................................................................. 2
Congestive heart failure .......................................... 2 Internal Appeals ................................................................. 23
Contact information .............. See bottom of pages Internal medicine doctors ................................................... 8
Copayment cap (pharmacy) ................................. 14 Inquiries .............................................................................. 22
Copayments (pharmacy) ...................................... 13 Manual breast pumps ......................................................... 2
Covered benefits............. see Covered Services list MassHealth .......................................................................... 1
Dental care for children ........................................ 17 Member Services Department ........................................... 1
Department of Children & Family (DCF) .............. 12 Membership ........................................................................ 1
Development problems (children) ....................... 18 Mental health services ........................................................ 10
Diabetes ................................................................. 19 New Member orientation ................................................... 1
Disenrollment ......................................................... 31 Not covered ......................................................................... 4
Doctor ....................................................................... 1 Nurse Advice Line from BMC HealthNet Plan .................. 2
Early and Periodic Screening ............................... 17 Obstetrician .......................................................................... 9
Diagnostic and Treatment (EPSDT)
OB/GYN ............................................................................. 16
Early intervention services .................................... 18
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
38
Over-the-counter medications ................................... 13
Pediatric doctors .......................................................... 9
Pharmacy ...................................................................... 2
Post-stabilization .......................................................... 4
Pregnancy ................................................................... 15
Prenatal care ............................................................... 15
Prescription medication coverage ............................ 13
Preventive care ........................................................... 13
Preventive Pediatric Healthcare ................................ 16
Screening and Diagnosis (PPHSD)
Primary Care Provider (PCP) ....................................... 1
Prior-Authorization ...................................................... 22
Privacy practices ........................................................ 27
Privacy complaint ....................................................... 30
Protected Health Information (PHI) ........................... 11
Provider Directory ......................................................... 1
Questions ...................................................................... 1
Referrals ........................................................................ 4
Responsibilities ........................................................... 21
Rights ........................................................................... 20
Services .............. (covered) see Covered Services list
Services not covered ...........see Covered Services list
Special healthcare needs ............................................ 1
Specialty care ............................................................... 4
Substance abuse services (including detoxification).. 10
Transportation assistance .......................................... 12
urgent Care .................................................................. 10
Web site ....................................... See bottom of pages
Well-child care ............................................................ 16
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
39
Details about Your Membership Card
Your Name Information that
enables you to have
Your personal prescriptions filled
BMC HealthNet Plan at any participating
Identification Number pharmacy
Your personal
doctor’s name
BMC HealthNet
Plan’s toll-free
Member Services
Department number
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
40
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
41
BMC HealthNet Plan Member Services Department MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
42
MH - HB 02/11 20M
BMC HealthNet Plan Member Services Department
Member Services Call Center MassHealth Customer Service
BMC HealthNet Plan
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012 8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) • 1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
Two Copley Place, Suite 600
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Boston, MA 02116
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
