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Forms, resources, and coverage criteria for your plan

These resources explain how we define services that are medically necessary.

Explore all Mass General Brigham Advantage medical necessity criteria and guidelines:

Mass General Brigham Health Plan medical policies

Optum behavioral health criteria

EviCore genetic testing criteria

Medical Necessity Criteria

View medical necessity criteria and guidelines from Mass General Brigham Health Plan.

First time users will be asked to create a One Healthcare ID account. Please enter your name and email address and accept the InterQual End User License Agreement to continue. You will then be redirected to our partner website for medical necessity criteria information.

Use these forms to submit a pharmacy claim or submit a new home delivery prescription order.
  • Optum Rx Medicare Part D Claim Form 2026 (PDF): 2026 | 2027 coming soon
  • Optum Rx Mail Order Form 2026 (PDF): 2026 | 2027 coming soon

Prior Authorization Information

Part B Medical Service Drugs Requiring Prior Authorization (PDF): 2026 | 2027 coming soon
These drug requests are submitted to Mass General Brigham Health Plan.



Part D Coverage Determination Requests

Medicare Prescription Drug Coverage Determination Request Form (PDF): 2026 | 2027 coming soon

Part D Coverage Redetermination Requests
Request for Redetermination of Medicare Prescription Drug Denial (PDF)

Part B Organization Determination Requests
Part B Prescription Medical Drug Organization Determination Request Form (PDF): 2026 | 2027 coming soon

Use these forms to enroll in a plan with us or review your rights and responsibilities if you want to change plans.

Use this form to give a friend, relative, doctor, or other person the right to legally represent you for healthcare coverage decisions.



If you would like a friend, relative, doctor, or other person to act for you as your “representative” to ask for a coverage decision (such as whether a service is covered) or make an appeal, you may need to appoint them as your representative. If that person is already legally authorized to act as your representative under state law, you do not need to appoint them to represent you. If you want to appoint someone to be your representative, complete the “Appointment of Representative” form. The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give Mass General Brigham Health Plan a copy of the signed form. You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or to appeal a decision.

Authorizations

Request For Medicare Service Coverage Determination (PDF)
This form can be used to submit information to Mass General Brigham Health Plan to help determine if a service or Part B Medical service drug is covered.

Use these documents for help with financial assistance, disaster relief, or to file a grievance or make an appeal.

Appeals and Grievances Data Report January 1, 2023 to December 31, 2023:

Use these resources to verify Mass General Brigham Health Plan Medicare star ratings.

2027 ratings


  • Coming soon

2026 ratings


If you would like to connect your health data to a selection of third-party mobile apps, you can do so by creating an account on our secure app connection platform. Learn how to create your account and connect your health data.

Complete this form after you have completed your Medicare-covered Annual Wellness Visit.

Please use this form to request copies of your protected health information contained within the designated record set maintained by Mass General Brigham Health Plan.

Prior authorization metrics report

To comply with the CMS Interoperability and Prior Authorization final rule, Mass General Brigham Health Plan is required to annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year. Publicly reporting these metrics promotes transparency and accountability, helps patients understand prior authorization processes, and enables providers to evaluate payer performance. In addition, metrics can be used to compare plans, programs, and payers.

View the report data

Utilization Management Health Equity Report

The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage plans to review prior authorization practices on a regular basis. CMS also requires plans to compare those practices amongst specific groups of members with social risk factors. Mass General Brigham Health Plan (MGBHP) recently conducted this review to ensure all members are treated equally regardless of those risk factors. Upon review, MGBHP has not identified any disparities within the groups that were included in the analysis. For more information, please click on the full report. 

View the full report

Have questions?

Ask a Medicare Advisor

Our dedicated Medicare Advisors are here to help. They can answer any questions about forms, policies, and coverage.

Call 855-486-3097

TTY 711

October 1 - March 31

8 a.m. to 8 p.m. ET, Monday-Sunday

April 1 - September 30

8 a.m. to 8 p.m. ET, Monday-Friday
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Mass General Brigham Health Plan is an HMO-POS/PPO organization with a Medicare contract. Enrollment in Mass General Brigham Health Plan depends on contract renewal. Other providers/pharmacies are included in our network.
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Mass General Brigham One Care is a Dual Special Needs Plan (D-SNP) that contracts with both Medicare and MassHealth (Medicaid) to provide benefits of both programs to enrollees. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is a voluntary program that is available to anyone age 21 - 64 who qualifies for MassHealth Standard or CommonHealth and Original Medicare and does not have any other comprehensive health insurance, except Medicare.
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Mass General Brigham SCO (Senior Care Options) is a Dual Special Needs Plan (D-SNP) with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is a voluntary program that is available to anyone 65 and older who qualifies for MassHealth Standard and Original Medicare and does not have any other comprehensive health insurance, except Medicare.
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Last updated: 10/1/2025

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