Skip to Content
Provider Portal Members About

Mass General Brigham SCO and One Care forms and documents

Find resources to help you use your plan and benefits.

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

Explore all medical necessity criteria and guidelines:

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.

These resources explain how to verify prescription drug coverage and how to submit requests and authorizations for medication.

Explore all drug coverage forms and resources:

OptumRx Mail Service Order Form (PDF) Coming soon
OptumRx Medicare Part D Prescription Claim Form (PDF) Coming soon

Coverage determination requests

Medicare Prescription Drug Coverage Determination Request Form (PDF) Coming soon
Part B Prescription Medical Drug Organization Determination Request Form (PDF) Coming soon

 

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

Mass General Brigham One Care Individual Enrollment Application (PDF) Coming soon

Mass General Brigham SCO Individual Enrollment Application (PDF) Coming soon

Disenrollment Rights & Responsibilities (PDF) Coming soon

Reimbursement forms

Use these forms to request reimbursements for qualifying healthcare expenses.

Medical Reimbursement Request Form (PDF) Coming soon

Behavioral Health Reimbursement Request Form (PDF) Coming soon

Flexible Benefit Card Reimbursement Form (PDF) Coming soon

Wig Reimbursement Request Form and Instructions (PDF) Coming soon

 

Vision reimbursement form

EyeMed Out of Network Reimbursement Form (PDF) Coming soon

 

Order forms

Use these forms to order products and prescriptions via mail.

OptumRx Mail Service Order Form (PDF) Coming soon

Over-the-counter (OTC) product order form (PDF) 

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) Coming soon
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.

Request For Medicaid Service Coverage Determination (PDF) Coming soon
This form can be used to submit information to Mass General Brigham Health Plan to help determine if a service is covered.

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

Grievances and Appeals (PDF)

Getting Care During a Disaster (PDF)

Mass General Brigham SCO (Senior Care Options) is a Coordinated Care plan 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.

Mass General Brigham One Care is a health plan 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.

Compare plans About Search for providers Meetings Look up Rx info Contact

© 2025 Mass General Brigham Health Plan, Inc. 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.

 

Y0166_0860MKT_M2025D

Last updated: 1/1/2025 - Pending CMS approval

Report a compliance issue Medicare complaint website Non-discrimination notice Disclaimer, privacy, and security Notice of privacy practices Web accessibility statement Multi-language interpreter services