MedicaidAdministrativeMedium impact
All Provider Bulletin 406: Update to Certain Exceptions to Services that Require Referrals in the Primary Care Clinician Plan and Primary Care ACOs
MassHealth·MA · Physical Therapy, Occupational Therapy, Emergency Medicine +3 more·Provider Bulletin
Effective date
Aug 1, 2025
We identified it
Jun 18, 2026
Summary
MassHealth has added 15 specific service categories that do not require referrals in the Primary Care Clinician Plan and Primary Care ACOs, expanding the exceptions list from the August 1, 2025 referral requirement reinstatement. These services can now be billed directly without obtaining a referral from the primary care provider.
Action Required
Immediately: Update billing system to remove referral requirements for the 15 newly exempted service categories including adult day health, doula services, early intervention, home health, physical/occupational/speech therapy, urgent care, and vaccine administration. Train billing staff on which services no longer need referrals. Verify that claims for these services can be submitted without PCP referral NPIs to avoid unnecessary denials.