INSURER FILING GUIDE
Mass General Brigham Health Plan
Use this public information to prepare your packet, then confirm the route on the insurer's own page.
AT A GLANCE
Claim facts
| Member form | Member Reimbursement Claim Form For Behavioral Health Services Number: 1122-04 Revision: Not published by the insurer Open the insurer form |
|---|---|
| Portal upload | Not published by the insurer |
| Portal path | Track costs and claims > behavioral health reimbursement e-form; attachment controls UNREADABLE |
| Mail address | Mass General Brigham Health Plan Claims, 399 Revolution Drive, Suite 810, Somerville, MA 02145 |
| Fax | 617-526-1902 |
| Attachments | Provider name; provider address; NPI and/or provider Tax Identification Number; patient name; dates of service; itemized charge for each date and service type; CPT, HCPCS, or revenue code; units for each procedure code; diagnosis codes; foreign currency name when applicable; proof of payment |
| Deadline | 12 months after the date of service |
| Outcome and status | Member portal or app > Track cost sharing and claims > claim status |
| Processing time | Most completed reimbursement requests are processed within 30 days |
| Caveats | The public text confirms an e-form but not attachment upload, so portal_upload remains Not published by the insurer. Optum handles behavioral appeals and grievances. HMO and EPO out-of-network coverage is plan-specific. Medicare Advantage and Medicaid are outside this read. |
STEP BY STEP
Filing steps
Source: https://resources.massgeneralbrighamhealthplan.org/member/MemberReimbursementForm_BH.pdf
Read date: 10-09-2026
Research steps
- Confirm that the behavioral health service is eligible for out-of-network reimbursement under the member's plan. Submit the request within 12 months after the service date. https://resources.massgeneralbrighamhealthplan.org/member/MemberReimbursementForm_BH.pdf
- Complete and sign form 1122-04. Add the itemized provider bill with every listed provider, patient, service, code, unit, diagnosis, charge, and foreign-currency field that applies, plus proof of payment. A superbill alone is not the complete package. https://resources.massgeneralbrighamhealthplan.org/member/MemberReimbursementForm_BH.pdf
- Sign in to the Mass General Brigham Health Plan Member portal or Health Plan Member app. Open Track costs and claims and use the behavioral health reimbursement e-form. https://resources.massgeneralbrighamhealthplan.org/member/MemberReimbursementForm_BH.pdf
- NOT PUBLISHED: whether the e-form accepts the signed PDF, itemized bill, and proof-of-payment attachments. Accepted file types, per-file size, maximum file count, one-PDF expectation, and submission confirmation are also NOT PUBLISHED. https://massgeneralbrighamhealthplan.org/members/memberapp
- Check the claim under Track cost sharing and claims. Most completed reimbursement requests are processed within 30 days. https://massgeneralbrighamhealthplan.org/members/memberapp https://resources.massgeneralbrighamhealthplan.org/member/MemberReimbursementForm_BH.pdf
Filing facts
- Portal upload: NOT PUBLISHED
- Portal: Mass General Brigham Health Plan Member portal or Health Plan Member app
- Portal path: Track costs and claims > behavioral health reimbursement e-form; attachment controls UNREADABLE
- Mail address: Mass General Brigham Health Plan Claims, 399 Revolution Drive, Suite 810, Somerville, MA 02145
- Fax: 617-526-1902
- Attach: provider name; provider address; NPI and/or provider Tax Identification Number; patient name; dates of service; itemized charge for each date and service type; CPT, HCPCS, or revenue code; units for each procedure code; diagnosis codes; foreign currency name when applicable; proof of payment
- File types: NOT PUBLISHED
- File size limit: NOT PUBLISHED
- Maximum files: NOT PUBLISHED
- One file or separate files: The claim requires a signed reimbursement form, itemized provider bill, and proof of payment; whether the e-form accepts this attachment package is NOT PUBLISHED
- Confirmation: NOT PUBLISHED
- Status check: Member portal or app > Track cost sharing and claims > claim status
- Processing time: Most completed reimbursement requests are processed within 30 days
- Member deadline: 12 months after the date of service
- Deadline basis: Plan-specific coverage controls whether an out-of-network service is eligible
- Mental health route: Optum for behavioral health appeals and grievances; behavioral reimbursement uses the Mass General Brigham Health Plan claim e-form
Confirm the address, fax number or portal path on the insurer's own claims page before you send; read on 10-09-2026.
Read on 10-09-2026 from https://resources.massgeneralbrighamhealthplan.org/member/MemberReimbursementForm_BH.pdf. Confirm the address, fax number or portal path on the insurer's own claims page before you send.