MedicaidAdministrativeMedium impact
All Provider Bulletin 409: Update to Certain Exceptions to Referral Requirements for Services through the Primary Care Clinician Plan and Primary Care Accountable Care Organizations
MassHealth·MA · Physical Therapy, Occupational Therapy, Family Medicine +4 more·Provider Bulletin
Effective date
Aug 1, 2025
We identified it
Jun 18, 2026
Summary
MassHealth has expanded the list of services that do not require referrals from Primary Care Clinicians (PCC) or Primary Care ACOs, effective August 1, 2025. The policy adds 16 specific service categories including doula services, restorative therapies, urgent care, and vaccine administration that can now be billed without PCC referrals.
Action Required
Immediately: Billing team must update referral requirements in billing system for MassHealth PCC Plan and Primary Care ACO members. Remove referral requirements for the 16 newly exempt services including adult day health, doula services, restorative therapies (PT/OT/speech), urgent care, and vaccine administration. Update staff training materials to reflect that these services can be billed directly without PCC referrals. Ensure claims for non-exempt services still include the referring provider's NPI.