Out-of-Network (OON) Services — Health Advantage preauthorization not required

Prior authorization is not required for certain out-of-network (OON) services for McLaren Health Advantage individual plans on the Exchange; providers must verify members' out-of-network benefits prior to services. Examples of OON categories with this rule include: OON ambulatory surgery centers (type of bill '83X'), OON outpatient facility services (revenue codes 0360, 0361, 0362, 0367, 0369, 0481, 0490, 0499, 0790, 0799), OON physician services (professional claims billed OON), and OON dialysis (Commercial/Community and Health Advantage only). Specialty medications/injections provided OON may also follow separate medical pharmacy guidance—verify benefits.

• Health Advantage individual Exchange plans: no Health Advantage preauthorization required for listed OON service categories
• Verify out-of-network benefits prior to receiving services

Occupational Therapy — preauthorization when exceeding benefit limits

Occupational therapy requires prior authorization only when requested services exceed the member's benefit limits. For Medicaid, a maximum of 144 billed units per calendar year applies; providers should call Customer Service to confirm available units. Health Advantage and Community lines: preauthorization is not required up to the benefit limit — refer to the Summary Plan Document or Certificate of Coverage for limits. Individual Exchange plans require in-network providers; preauthorization not required up to benefit limit.

• Medicaid: max 144 billed units/year; call Customer Service to confirm
• Preauthorization required only when exceeding benefit limits for all lines of business

Physical & Speech Therapy — preauthorization up to/over benefit limits

Physical and speech therapy (including rehabilitation services) do not require prior authorization when provided within the member's benefit limits. For Medicaid, the maximum billed units for physical/rehabilitation services is 144 units per calendar year; speech therapy has a Medicaid benefit limit of 36 visits per calendar year. Preauthorization is required for any requests that exceed benefit limits. Individual Exchange plans require in-network providers and follow the Certificate of Coverage for limits.

• Physical Therapy — Medicaid: max 144 billed units/year; preauth only when exceeding limits
• Speech Therapy — Medicaid: max 36 visits/year; preauth only when exceeding limits
• All lines: preauthorization required when requests exceed benefit limits

Reproductive Services & Infertility — preauthorization notes and exceptions

Reproductive and infertility services include a broad set of CPT/HCPCS and procedure-specific codes. Health Advantage does not require preauthorization for termination of pregnancy codes. Voluntary sterilization for Medicaid requires preauthorization plus a signed consent form and a 30-day waiting period (consent documentation must be submitted). For other reproductive/infertility procedures, follow the code list and the applicable line-of-business rules; requests exceeding benefit limits require authorization.

• Infertility and GYN procedure codes listed in the reproductive services code list (see policy)
• Termination of pregnancy (listed codes): Health Advantage preauthorization not required
• Medicaid voluntary sterilization: preauthorization + signed consent + 30-day waiting period; submit consent with request

Spine Procedures — authorization required for Medicaid and Community/On-Exchange

Spine procedures require prior authorization for Medicaid and Community/On-Exchange members for procedures performed in any setting, including inpatient hospital, outpatient, or ambulatory settings. Providers must obtain authorization prior to performing listed spine procedure codes.

• Auth required for Medicaid and Community/On-Exchange for spine procedures in ALL settings
• Refer to the policy's spine procedure code list (e.g., 0200T, 22100–22114, 22206–22220, 22510–22590, 22600–22633, 22800–22899, 63001–63286, 63300–63308, etc.)

Transplant Services — preauthorization and Medicaid exceptions

Transplant services generally require preauthorization. Specific organ rules for Medicaid: cornea and kidney transplants do not require authorization when performed standalone; however, if performed during a hospital stay, an inpatient authorization is required. Other transplant types (heart, liver, lung, marrow, pancreas, intestine, islet, stem cell) follow the transplant preauthorization requirements and associated code lists — obtain authorization per policy.

• Cornea transplant (Medicaid only): no auth required unless performed during a hospital stay (then inpatient auth required)
• Kidney transplant (Medicaid only): no auth required unless during hospital stay (then inpatient auth required)
• All other listed transplants (heart, liver, lung, marrow, pancreas, intestine, islet, stem cell): preauthorization required

Transport & Urgent Request Rules — air ambulance review and non-emergency transport preauth

Transportation services: emergency air ambulance transports (A0430, A0431, A0435, A0436) are subject to retroactive medical necessity review. Non-emergency ground ambulance and other transport services may require prior authorization per the preauthorization grid; urgent authorization requests are limited to situations where delay could jeopardize life/health, the ability to regain function, or subject the member to severe unmanaged pain.

• Emergency air ambulance (A0430, A0431, A0435, A0436): requires retro medical necessity review
• Non-emergency ambulance (A0021, A0380, A0382, A0384, A0390, etc.): follow preauthorization grid
• Urgent requests: defined as requests where delay could jeopardize life/health, recovery, or cause severe unmanaged pain

Medication (J-code) Requirements & Audit Notice

Medications billed with J-codes and certain C/Q/S codes require prior authorization when prescribed outside FDA or manufacturer guidelines. The medical pharmacy (Buy & Bill) program includes many J-code medications; some 'carved out' J/C/S/Q codes administered by physicians must be billed Fee-For-Service for Medicaid. The authorization list is updated at least quarterly and McLaren reserves the right to perform post-payment audits for medical necessity and adherence to industry standards.

• Any medication (J-Code) prescribed against FDA/manufacturer guidelines requires preauthorization
• Buy & Bill (Medicaid only): certain carved-out C, J, S, Q codes must be billed Fee-For-Service
• Authorization lists for J/C/S/Q codes are updated quarterly; ad hoc post-payment audits may occur

Preauthorization Guidance & Contact Information

Submit prior authorization requests using the Provider Referral and Preauthorization Form and refer to the Certificate of Coverage, Summary Plan Document, or Policy for detailed benefit limits and requirements. For questions or clarifications, contact McLaren Health Plan Customer Service at (888) 327-0671. Dental prior authorizations must be submitted directly to Delta Dental at 1-866-558-0280.

• Provider Referral and Preauthorization Form required for submissions
• Customer Service: (888) 327-0671
• Dental prior authorizations: submit to Delta Dental at 1-866-558-0280

Medical Pharmacy Examples & Billing Note (Buy & Bill)

Examples of medical pharmacy (Buy & Bill) J-codes and sample specialty medications are listed in the policy (e.g., J0217 Velmanase alfa; J0738/J0752 lenacapavir/Yeztugo; J0739 Apretude; J0741 Cabenuva; J1322 Vimizim; J1411 Hemgenix; J1413 Elevidys). For Medicaid-only 'Buy & Bill' carved-out codes, physicians must bill Fee-For-Service. New or temporary C/J/S/Q codes may require authorization; always verify current list on McLarenHealthPlan.org.

• Sample J-codes: J0217 (Velmanase alfa), J0739 (Apretude), J0741 (Cabenuva), J1322 (Vimizim), J1411 (Hemgenix), J1413 (Elevidys)
• Medicaid Buy & Bill: physicians administering carved-out codes must bill Fee-For-Service
• Temporary or newly released C/J/S/Q codes may require authorization — check quarterly updates

Cancer-Diagnosis & Code-Specific Authorization Exceptions

For many specialty medications/injections listed in the policy, if the submitted claim primary diagnosis is cancer, preauthorization is not required for in-network facilities for those codes flagged with 'No auth Cancer diagnosis, in network facilities'. Codes without that flag still require authorization per the list. Newly added or temporary codes may also require prior authorization.

• Codes flagged '**No auth Cancer diagnosis, in network facilities' — no in-network preauthorization required when primary diagnosis is cancer
• All other specialty medication codes: follow authorization requirements in the list
• Check the policy for recent additions/changes (quarterly updates)

Site-of-Care Restriction for Certain Infusion Codes

Site-of-care restrictions apply for Health Advantage and Community Plans (Large Group, Small Group, Individual). Certain infusion codes are excluded from hospital infusion settings and must be administered either in the member's home by a home health care provider or at a freestanding infusion center not located within or affiliated with a hospital. Providers must follow site-of-care direction for the specified codes.

• Site-of-care restriction: excluded from hospital infusions — only home health or non-hospital-affiliated infusion centers
• Applies to Health Advantage and Community plans

Site-of-Care Restriction — exclusion from hospital infusion

Some codes are explicitly excluded from being billed as hospital infusions and are restricted to home or non-hospital infusion centers (see the policy's site-of-care code list). Verify the member's plan (Health Advantage/Community) and ensure infusion location complies with site-of-care rules to avoid claim denials or payment adjustments.

• Codes excluded from hospital infusions must be provided by home health or non-hospital infusion centers
• Verify member plan and infusion site to prevent denials

Service Listings & Preauthorization/Referral Designations

This document includes a preauthorization/referral grid and service listing that designates which categories require prior authorization, which require only notification, and which are subject to benefit-limit-only authorization. Providers must consult the grid and the Certificate of Coverage or Summary Plan Document for line-of-business–specific authorization and referral designations.

• Service listings in the referral/preauthorization grid designate preauth vs notification vs benefit-limit-only auth
• Consult Certificate of Coverage or Summary Plan Document for line-of-business specifics

Experimental / Off-Label Services — prior authorization notice

McLaren Health Plan does not pay for services, treatments, or drugs that are experimental, investigational, or prescribed against FDA or manufacturer guidelines. Any service that may be classified as experimental or off-label should be prior authorized before the service is rendered. Requests for services that are cosmetic in nature will be subject to clinical review.

• Experimental/investigational/off-label services require prior authorization before rendering
• Cosmetic procedures subject to clinical review and may be denied if not medically necessary