General preauthorization rule

Prior authorization is required by McLaren for all products for both primary or secondary payer unless Medicare is the primary payer (for hospital services only).

Neurostimulator: trial and permanent each require auth

Two separate authorizations are required for neurostimulator procedures: one authorization for the trial and a separate authorization for the permanent insertion.

Medicaid home care first 24 visits no auth; additional visits require authorization

For Medicaid only, the first 24 billed home care visits per calendar year do not require prior authorization; any additional home care visits beyond those first 24 billed visits require authorization.

• Home Health providers should call to verify how many annual visits have already been billed to prevent claims denial.

CGMs and insulin pumps require preauthorization (with limited Medicaid CGM exceptions)

All codes for continuous glucose monitors (CGMs), insulin pumps, and associated supplies require preauthorization; specified Medicaid exceptions for CGMs and supplies (type I diabetes and diabetes in pregnancy/childbirth/puerperium) became effective May 1, 2023, and A9278 noted effective 1/1/2025.

• Insulin pumps and supplies continue to require prior authorization.
• Smart devices used with a CGMS are not covered by Medicaid (per MDHHS guidance) as of 1/1/25.

Authorization guidelines: medical necessity, J‑code rule, and quarterly updates

This is not a complete listing; all services must be medically necessary. Any medication (J‑Code) prescribed against FDA/manufacturer guidelines requires preauthorization. The list is updated at least quarterly; contact MHP Customer Service for questions.

• Provider Referral and Preauthorization Form, Certificate of Coverage, Plan Document or Policy contains additional detail.
• MHP reserves the right to perform ad hoc post-payment audits and to subject cosmetic procedures to clinical review.

Therapy auth: no auth up to benefit limits; auth required if exceeding limits

Preauthorization is not required for Occupational, Physical and Speech Therapy up to each plan's benefit limit; preauthorization is required for requests over the benefit limit. Medicaid limits include a maximum of 144 billed rehab units per calendar year and speech therapy is not authorized beyond 36 visits per calendar year without prior auth.

• Health Advantage and Community plans: preauthorization not required up to benefit limits — refer to plan documents for limits.
• For requests over benefit limits across all lines of business, prior authorization is required.

Transportation: emergent air ambulance retro review; meals/lodging notification rules

Emergency air ambulance transports require retroactive medical necessity review; meals and lodging require health plan notification for Medicaid (and are transplant-related only for Health Advantage). Non‑emergency ambulance and other listed transportation codes require authorization per the grid.

• Emergency Air Ambulance definitions include HCPCS A0430, A0431, A0435, A0436.
• Meals/Lodging definitions reference A0080–A0210 and require notification or preauthorization per plan.

Provider instructions: consult referral form, plan documents, and Customer Service

This is not a complete listing of services that may require preauthorization; all services must be medically necessary. Providers must consult the Provider Referral and Preauthorization Form, Certificate of Coverage, Plan Document or Policy and contact MHP Customer Service for questions.

• Use the Provider Referral and Preauthorization Form and plan documents for referral and preauthorization details.
• The list is updated at least quarterly on McLarenHealthPlan.org.

Cancer diagnosis exception: asterisked codes in‑network do not require auth

If the submitted claim primary diagnosis is cancer, preauthorization for in‑network facilities is not required for codes listed with asterisks. Newly released or temporary C, J, S, Q codes may still require authorization.

• Codes annotated '**No auth Cancer diagnosis, in network facilities' do not require authorization when primary diagnosis is cancer and service is in‑network.
• Temporary/miscellaneous/newly released codes should be checked for authorization requirements.

Medicaid Buy & Bill: carve‑out C/J/S/Q codes must be billed FFS

Buy & Bill (Medicaid only): physicians administering 'Carved Out' C, J, S, and Q codes must bill Fee‑For‑Service (Medicaid Buy & Bill requirement).

Code removals: certain J‑codes show 'Removed' with effective dates

Some J‑codes in the specialty medications list have been marked 'Removed' with effective dates (for example entries showing removals effective 1/1/2026), indicating those codes/products are no longer listed or mapped in the grid after the removal date.

• Examples in the grid show 'Removed 1/1/2026' annotations for specific entries.

Authorization note: '**No auth Cancer diagnosis, in network facilities' applies

Multiple entries are annotated '**No auth Cancer diagnosis, in network facilities.' — providers should not submit prior authorization for these codes when the primary diagnosis is cancer and the service is provided in‑network.

General authorization requirements and submission guidance

Providers must submit prior authorization requests as specified; medications prescribed against FDA/manufacturer guidelines require preauthorization. The list is updated at least quarterly and the most current version is available at McLarenHealthPlan.org.

• Contact MHP Customer Service at (888) 327-0671 with questions.

Dental prior authorization: submit requests to Delta Dental

Submit dental prior authorization requests directly to Delta Dental at 1-866-558-0280 for the listed dental codes (e.g., D2710–D4342).

• Examples of dental codes requiring preauthorization include D2710, D2740, D4341, D4342.

Preauthorization/notification overview: inpatient auths and OON considerations

Many services require preauthorization or admitting‑facility‑obtained authorizations for inpatient services; deliveries without sterilization require notification only. Out‑of‑network services may be reimbursed at out‑of‑network benefit levels — verify per plan.

• All inpatient services are generally authorized by the admitting facility unless exceptions apply.
• Individual plans on the Exchange should verify out‑of‑network benefits prior to services.

Service-specific notes: emergent air ambulance post‑service review and variable coverage for ABA/BAHA

Certain ambulance air emergent transports require post‑service review. Services such as Applied Behavioral Analysis (ABA), Autism Services, and BAHA have varying coverage status or may require riders or authorization depending on plan.

• Ambulance: Air, Emergent requires post‑service review.
• BAHA devices (L8691–L8694) may require a commercial rider.

Auth required only when exceeding benefit limits for select services

Authorization is required only when services exceed benefit limits for categories such as Transitional Case Management, Transplant Services, Transportation, Vision Services, and specific procedures; transplant authorization is tied to organ‑specific limits.

• Transitional Case Management and Transplant Services require auth only when exceeding benefit limits — consult plan documents for organ‑specific rules.