MedicaidPrior AuthHigh impact
All Provider Bulletin 418: Update to Certain Exceptions to Referral Requirements through the Primary Care Clinician Plan and Primary Care Accountable Care Organizations: Radiology and Imaging
MassHealth·MA · Radiology·Provider Bulletin
Effective date
Aug 1, 2026
We identified it
Jul 31, 2026
Summary
Effective August 1, 2026, MassHealth eliminates referral requirements for all radiology and imaging services provided to members in the Primary Care Clinician (PCC) Plan or Primary Care ACO. However, these services remain subject to ordering, referring, and prescribing (ORP) provider requirements. This change simplifies access to imaging but does not eliminate all authorization requirements.
Action Required
By August 1, 2026: Billing team must update billing system workflows to remove referral requirement validation for radiology and imaging services billed to MassHealth PCC Plan and Primary Care ACO members. Update claim submission logic to stop denying claims for missing PCC referrals on these services. Providers must continue to ensure ORP provider requirements are met (see All Provider Bulletins 286, 361, 376, 380, 391, 403, and 409 for ORP details). Update internal documentation and staff training to reflect that radiology/imaging no longer requires PCC referrals. Verify that claims previously denied for missing referrals on radiology/imaging services are reviewed for resubmission. Monitor initial claim submissions post-August 1 for any system errors that may still reject valid claims.