Preauthorization required for most services

Preauthorization is required by McLaren for all products for both primary or secondary payer unless Medicare is the primary payer (for hospital services only). Providers must submit prior authorization for services and codes listed in the document and consult the preauthorization grid for line-of-business specific rules and exceptions.

• Submit prior authorization for services and codes listed in this document.
• Consult the preauthorization grid for line-of-business specific rules and exceptions.
• Medicare-primary hospital services are excluded from this preauthorization requirement.

Neurostimulator authorizations

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

• Submit one authorization for the neurostimulator trial.
• Submit a separate authorization for the permanent insertion.

Medical necessity and audit risk

All services must be medically necessary. McLaren reserves the right to perform ad hoc post-payment audits to determine medical necessity and adherence to industry-standard treatment protocols; cosmetic procedures may be subject to clinical review at any time.

• Services must be medically necessary or they may be denied or recouped after audit.
• McLaren may perform post-payment/ad hoc audits and clinical reviews, including for cosmetic procedures.

Home care billing guidance (Medicaid)

For Medicaid only, home health is billed on institutional claims (type of bill 311–389 and revenue codes 0550–0559). Effective 1/1/2020, the first 24 billed home care visits per calendar year do not require prior authorization; additional visits require authorization and providers should verify previously billed visits to avoid claim denial.

• Home Health billed on institutional claim type of bill 311–389 and revenue codes 0550–0559.
• First 24 billed home care visits per calendar year do not require prior authorization for Medicaid.
• Verify previously billed visits before billing to prevent claim denial; additional visits require authorization.

Inpatient authorization exception for routine deliveries

All inpatient stays require authorization except routine delivery without sterilization, which requires notification only for all lines of business.

• Admitting facility obtains authorization for inpatient stays.
• Routine delivery without sterilization requires notification only (no prior authorization).

Genetic testing review

All genetic testing codes may require Medical Director review and preauthorization even if a specific code is not listed; see the Genetic Testing Code List for details.

• Medical Director review may be required for genetic/molecular testing codes.
• Preauthorization may be required even for codes not explicitly listed in the main code list.

CGM/Insulin pump exception (Medicaid)

Effective May 1, 2023, for Medicaid only, prior authorization is not required for Continuous Glucose Monitors and supplies for members with type I diabetes or diabetes in pregnancy/childbirth/puerperium; insulin pumps continue to require authorization.

• Medicaid exception effective May 1, 2023: CGMs and supplies do not require prior authorization for members with type I diabetes or diabetes in pregnancy/childbirth/puerperium.
• Insulin pumps still require prior authorization.

Buy & Bill (Medicaid) carve-out

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

• Physicians must bill Fee‑For‑Service for carved-out C/J/S/Q codes under Medicaid.

Medicaid Only - Fee for Service for Carved-Out C/J/S/Q codes

Physicians administering 'Carved Out' C, J, S, and Q codes for Medicaid must bill Fee‑For‑Service (buy & bill) as indicated in the Medical Pharmacy Buy & Bill section.

• Medicaid-only requirement: bill Fee‑For‑Service for carved-out C/J/S/Q codes.

Cancer primary diagnosis - preauthorization not required for certain codes in-network

If the submitted claim primary diagnosis is cancer, preauthorization for in‑network facilities is not required for codes listed with asterisks/**. Check code entries for '**' and accompanying notes to identify exempt codes.

• Codes marked with '**' include an annotation indicating no authorization is required when the primary diagnosis is cancer and the service is provided at an in‑network facility.
• Review the code list to find codes marked with '**' to apply the cancer diagnosis exemption.

Authorization may be required for temporary/misc/new codes

Any temporary, miscellaneous, or newly released C, J, S, or Q codes may require authorization; verify before billing.

• Temporary/misc/new C/J/S/Q codes may require prior authorization—confirm prior to service.
• The policy is not a complete listing; always verify current requirements.

Code updates and removals

The code list contains codes that have been removed or changed to different codes (examples: C9142 changed to Q5126; multiple removals dated 1/1/2026 or earlier). Billing staff must use current code mappings and modernized codes on claims.

• Use current code mapping; some codes have been removed or remapped (dates noted in list).
• Examples: C9142 changed to Q5126 (Removed/Changed dates are provided in code entries).

Hospital infusion exclusion for specified codes

Certain drugs are excluded from hospital infusions and must be administered in the member's home by a home health provider or at an infusion center not located within or affiliated with a hospital; this site‑of‑care restriction applies to Health Advantage and Community Plans.

• Codes excluded from hospital infusion must be given at home or at a non‑hospital-affiliated infusion center.
• Applies to Health Advantage and Community Plans (Large Group, Small Group, Individual Group).

Billing requirement for J0256

When administering alpha‑1 proteinase inhibitor (J0256), providers must bill S9346 (Home Infusion) alongside J0256 as specified.

• Codes: J0256 and S9346
• Must bill S9346 (Home Infusion) for J0256 per site‑of‑care instruction.

Preauthorization required for many services

Many categories of services require prior authorization, including DME purchases/rentals beyond thresholds, transplants when exceeding benefit limits, and select procedures (e.g., spine, ECT, certain therapies); obtain authorization when services exceed benefit limits or per category designations.

• DME purchases/rentals above thresholds require authorization (thresholds vary by line of business).
• Transplants and select procedures require authorization when exceeding benefit limits.
• Spine procedures and other listed categories require prior authorization as noted.

Medicaid sterilization

Medicaid sterilization requests require informed consent and a 30‑day waiting period; copies of consent must be submitted with the preauthorization request.

• Obtain signed informed consent for sterilization.
• A 30‑day waiting period is required and consent copies must accompany the authorization request.

Experimental/Investigational or off-label services

McLaren does not pay for services, treatments, or drugs that are experimental, investigational, or prescribed against FDA or manufacturer guidelines; such services should be prior authorized before they are rendered to avoid denial.

• Experimental, investigational, or off‑label services are not payable without prior authorization.
• Prior authorization should be obtained before rendering such services to avoid denial.

Medicaid mental health services management

Medicaid/Healthy Michigan behavioral health benefits may be managed by Prepaid Inpatient Health Plans (PIHP) or Community Mental Health Centers (CMH); route authorizations accordingly rather than to McLaren when managed by PIHP/CMH.

• Medicaid/Healthy Michigan inpatient behavioral health benefits are managed by the PIHP.
• Providers should route behavioral health authorization requests to PIHP/CMH when applicable.

Out-of-Network cost and verification

Members have higher out‑of‑pocket costs for out‑of‑network providers; Individual Exchange plans should verify out‑of‑network benefits prior to services and not all out‑of‑network services require preauthorization for some Health Advantage/Community/Commercial plans.

• Verify out‑of‑network benefits for Individual Exchange plans prior to services.
• Not all out‑of‑network services require preauthorization for some plans—confirm per plan rules.
• Expect higher member cost‑sharing for out‑of‑network services.