Our Programs

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Office of Clinical Affairs

The Office of Clinical Affairs, part of the Center for Health Policy and Research, provides clinical leadership to MassHealth, the Massachusetts Medicaid program. In this role, we support a full range of medical management functions, including clinical policy, utilization management, pharmacy, quality, clinical informatics, and oral health on behalf of MassHealth programs.

Working closely with MassHealth since 2001, we ensure that patients receive medically necessary, appropriate, cost-effective, quality care — in compliance with state and federal regulations.

Program measurement and analysis

Our team provides MassHealth with measurement and analysis expertise to ensure that programs meet required quality standards. Our services include the following:

  • Program and policy evaluation
  • Qualitative data collection and analyses
  • Quantitative analyses including statistical analyses
  • Development of measures and dashboards
  • Reporting and analysis of medical trends/utilization
  • SAS and ACCESSdb programming

Policy Development

We approach the development of medical policies from a variety of angles and tap a wide variety of sources to inform the policy recommendations we make to MassHealth. Our team is well-versed in conducting all of the following activities to construct policy:

  • Environmental scans
  • Medical literature review
  • Critical analysis of the evidence-based literature
  • Medical necessity guideline development
  • Comparative effectiveness research
  • Engagement and peer review with key leaders and clinical experts 

Pharmacy

As we administer the MassHealth pharmacy program, our goal is to ensure that it delivers necessary pharmacy services at the lowest cost and at an appropriate level of care. Our team ensures that the money spent provides the highest value for both Massachusetts and members of MassHealth.

To achieve this, we provide a full range of pharmacy services for MassHealth:

  • Pharmacy benefit implementation and operations
  • Pharmacy informatics
  • Drug therapy claims analysis
  • Pharmacy benefit design
  • Comparative effectiveness evaluations

Utilization Management & Prior Authorization

Our team ensures that MassHealth has the complete utilization management and prior authorization services it needs:

  • Management of vendor contracts
  • Prior authorization
  • Care coordination and management
  • Program integrity and fraud review, as well as medical records review
  • Representation at MassHealth administrative hearings

Dental Management

With a team of dental experts working directly with MassHealth, we provide the following:

  • Regulatory development and support
  • Dental policy development
  • Utilization management and review as well as quality oversight of dental programs
  • Collateral agency support and compliance for the state Office of the Attorney General