Currentmclaren health planPolicy N/A

Service Codes Requiring Prior Authorization and Related Preauthorization Rules

Lists services, CPT/HCPCS/HCPCS-like codes and categories that require prior authorization across McLaren Health Plan product lines and notes product-specific exceptions (Medicaid, Healthy Michigan, Commercial/Community, Health Advantage); applies to providers and facilities submitting authorization requests.

Policy Summary

Payermclaren health plan

PolicyService Codes Requiring Prior Authorization and Related Preauthorization Rules

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization from McLaren for listed services when required before rendering, except where per-code or product-specific exceptions apply.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleService code lists

variesDME thresholds

Medicaid exceptionCGM exception

auth reqdInpatient stays

2 authsNeurostimulator

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

DeltaDentalDental auth submission

Services and Preauthorization Coverage Criteria

Preauthorization criteria and exceptions

Many specific CPT/HCPCS and related codes require prior authorization. Exceptions and product-specific thresholds are noted below.

Specific listed codes and code ranges require preauthorization for the applicable product lines.

Exceptions

Autism services and ABA do not require authorization up to the benefit limit for Community/Commercial and Health Advantage; autism and ABA services are not covered by the plan for Medicaid.
BAHA (hearing device) codes: Medicaid only — authorization is not required if services are provided in-network; otherwise listed auditory/oral procedure codes require authorization.

Preauthorization criteria by service and line of business

Preauthorization requirements vary by service and line of business. Typical pattern: no preauthorization up to benefit limits; authorization required when limits are exceeded or for specific settings.

ALL of the following

Occupational therapy: preauthorization not required up to the benefit limit (all lines); preauthorization required for requests over the benefit limit; Medicaid maximum 144 billed units per calendar year.

ALL of the following

Physical therapy: preauthorization not required up to the benefit limit (all lines); preauthorization required for requests over the benefit limit; Medicaid maximum 144 billed units per calendar year.

ALL of the following

Speech therapy: Medicaid — preauthorization not required up to the benefit limit of 36 visits per calendar year; other lines — preauthorization not required up to their benefit limits; preauthorization required for requests over benefit limits.

ALL of the following

Spine procedures: authorization required for Medicaid and Community/On-Exchange plans for procedures in all settings, including inpatient.

Coverage statements and authorization exceptions

General coverage and authorization guidance for listed codes.

All services must be medically necessary; this listing is not exhaustive — refer to the Provider Referral and Preauthorization Form, Certificate of Coverage, Plan Document or Policy for detailed coverage and limits.

Any medication prescribed against FDA or manufacturer guidelines requires prior authorization.

Cancer-diagnosis exceptions: Certain specialty medication codes marked in the list do not require preauthorization when the submitted claim primary diagnosis is cancer and the service is provided in-network (per-code exceptions are noted inline).

Buy & Bill (Medicaid): physicians administering carved-out C, J, S, and Q codes must bill Fee for Service as noted in the medical pharmacy section.

Coverage-related notes

Per-code coverage notes and lifecycle annotations appear inline with many J-code entries.

Many J-code entries include inline notes such as 'No auth Cancer diagnosis, in network facilities' that remove the preauthorization requirement when the primary diagnosis is cancer and the service is provided in-network.

Some J-code entries include 'added' or 'removed' dates (code lifecycle notes) — providers should follow the effective/removed dates shown for each code.

Certain entries explicitly exclude biosimilars (example: filgrastim entry excludes biosimilars) — follow the entry-level exclusions/notes when submitting authorizations or claims.

Coverage notes and site-of-care constraints

Oncology-related J- and Q-code entries often include authorization exceptions tied to cancer diagnosis and facility/network status.

Codes annotated '**No auth Cancer diagnosis, in network facilities' do not require prior authorization when used for a cancer diagnosis and administered in-network.

Codes show effective/add dates and should be handled according to those date annotations (e.g., added 1/1/2023; changed or added on later dates).

Some oncology codes have multiple notation lines indicating both addition and the cancer-diagnosis in-network exception; follow the code-level notes when requesting authorization.

Site-of-care and preauthorization criteria

Administration location and site-of-service rules and thresholds apply to DME, prosthetics/orthotics and selected procedures.

DME/prosthetics purchase and rental thresholds trigger authorization: Medicaid/Healthy Michigan purchase > $1,500; Commercial/Community HMO & POS purchase > $3,000; Health Advantage purchase > $5,000. Rental thresholds and line-of-business variances are noted in the thresholds section.

Certain DME and orthotic items are listed as authorization not required for Medicaid and Health Advantage when specific L-codes are provided in-network (see list of L-codes in the DME section).

All inpatient stays require authorization except routine delivery (notification only); neurostimulator procedures require separate authorizations for trial and permanent insertion.

NC-specific preauthorization/referral designations

State grid designations and plan-specific notes indicate when preauthorization or referral is required for North Carolina lines of business.

NC grid designations (X, NR, NC, see grid) apply across many service categories — consult the grid for the required action per service and plan type.

Examples: Infertility testing and services (NC = X), Insulin pumps/supplies (NC = X), Prosthetics and orthotics thresholds indicated (NC = >$500, >$3,000, >$5,000).

Specialty/high-cost services

High-cost items and specialty medications require attention to thresholds, site-of-service, and frequent list updates.

Specialty medication J/Q/C codes frequently include site-of-care and diagnosis-based exceptions; the medical pharmacy list is updated at least quarterly and may require preauthorization per program rules.

Post-payment audits may be performed to confirm medical necessity for high-cost items; any medication prescribed against FDA/manufacturer guidelines requires prior authorization.

DME purchase/rental thresholds and prosthetics/orthotics dollar thresholds apply and vary by line of business — see DME/threshold entries for exact dollar or monthly limits.

Auth when exceeding benefit limits

Certain services require authorization only when benefit limits are exceeded; transplant services have organ-specific rules.

Services listed as 'auth required only when exceeding benefit limit' (e.g., Transitional Case Management, select Transplant Services, Transportation, Vision Services, Urologic procedure 55880) require preauthorization once the plan benefit limit is exceeded — verify with plan documents and customer service.

Transplant services: consult the organ-specific guidance in the grid and plan documents for thresholds and whether authorization is required (some transplants may be authorized only when benefit limits are exceeded).

Code Lists and Billing Thresholds

Auditory/Oral/Oral Surgery & Related CPT Codes (selected)CPTCovered

21025	Oral surgery/mandibular
21026	Oral surgery/mandibular
21029	Oral surgery/mandibular
21030	Oral surgery/mandibular
21120	Orbital/zygomatic procedures
21121	Facial bone procedures
21122	Facial bone procedures
21123	Facial bone procedures
21193	Treatment to correct obstructive sleep apnea (graft/cartilage)
21194	Treatment to correct obstructive sleep apnea

1–10 of 19

1/2

Durable Medical Equipment (DME) HCPCS — examples requiring authHCPCSCovered

E0193	Nebulizer/compressor; with face mask (authorization required per LOB)
E0236	Durable medical equipment component (authorization required)
E0301	Traction equipment, cervical
E0302	Traction equipment, lumbar
E0303	Traction equipment
E0304	Traction equipment
E0305	(series)
E0316	Crutch replacement (example)
E0328	Home ventilator interface
E0329	Ventilator circuit components

1–10 of 43

1/5

Radiation & Photochemotherapy CodesCPTCovered

96573	Phototherapy, UVB, psoralen
96574	Photochemotherapy, PUVA
96910	Photodynamic therapy, initial session
96912	Photodynamic therapy, additional areas
96913	Photodynamic therapy, subsequent sessions
96920	Photopheresis, therapeutic
96921	Photopheresis, therapeutic
96922	Photopheresis, therapeutic
77520	Proton beam therapy, simple
77522	Proton beam therapy

1–10 of 14

1/2

Spine Procedures Requiring Authorization (selected)CPTCovered

0200T	Spine procedure (T-code)
22100	Partial corpectomy
22101	Partial corpectomy
22102	Partial corpectomy
22110	Vertebral body procedures
22112	Vertebral body procedures
22114	Vertebral body procedures
22206	Corpectomy, vertebral body, anterior
22207	Corpectomy, vertebral body
22210	Vertebral procedures

1–10 of 57

1/6

Genetic / Molecular Testing Codes (CPT/HCPCS/U-codes) — consolidatedmixedCovered

81161	Molecular pathology procedure
81162	Molecular pathology procedure
81163	Molecular pathology procedure
81164	Molecular pathology procedure
81165	Molecular pathology procedure
81166	Molecular pathology procedure
81167	Molecular pathology procedure
81168	Molecular pathology procedure
81169	Molecular pathology procedure
81170	Molecular pathology procedure

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1/7

Genetic / Molecular Testing — U-code series (selected)mixedCovered

0001U	Proprietary genomic test example
0003U	Proprietary genomic test example
0005U	Proprietary genomic test example
0007U	Proprietary genomic test example
0016U	Proprietary genomic test example
0017U	Proprietary genomic test example
0022U	Proprietary genomic test example
0023U	Proprietary genomic test example
0026U	Proprietary genomic test example
0029U	Proprietary genomic test example

1–10 of 51

1/6

Genetic / Molecular Testing — Continued U-code & G-code entriesmixedCovered

0331U	Proprietary genomic test
0332U	Proprietary genomic test
0333U	Proprietary genomic test
0335U	Proprietary genomic test
0336U	Proprietary genomic test
0339U	Proprietary genomic test
0340U	Proprietary genomic test
0341U	Proprietary genomic test
0343U	Proprietary genomic test
0345U	Proprietary genomic test

1–10 of 52

1/6

Specialty Medication J/Q/C Codes (selected examples)HCPCSCovered

J7168	Kcentra — Prothrombin complex concentrate (human) per I.U. of factor IX activity
J7169	Andexxa — coagulation factor XA recombinant (andexxa)
J7170	Hemlibra — emicizumab-kxwh
J0217	Lamzede — velmanase alfa-tycv
J0739	Apretude — cabotegravir (PrEP)
J0741	Cabenuva — cabotegravir/rilpivirine
J1411	Hemgenix — etranacogene dezaparvovec-drlb (gene therapy)
J3398	Luxturna — voretigene neparvovec-rzyl (gene therapy)
J3399	Zolgensma — onasemnogene abeparvovec-xioi (gene therapy)
Q2041	Yescarta — axicabtagene ciloleucel (CAR-T)

1–10 of 11

1/2

Sample J-code entries (examples)HCPCSCovered

J1322	Vimizim — elosulfase alfa
J1413	Elevidys — delandistrogene moxeparvovec-rokl
J1414	Beqvez — fidanacogene elaparvovec-dzkt (gene therapy)

Hemostasis & Biologics J-codes (selected)HCPCSCovered

J7168	Kcentra — Prothrombin complex concentrate
J7169	Andexxa — coagulation reversal agent

Provider Responsibilities, Prior Authorization & Billing Rules

Prior Authorization

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

Prior Authorization

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.

Definitions and Product-Specific Notes

Autism Services / ABA

Authorization rule for ABA/autismAutism services and ABA do not require authorization up to the benefit limit for Community/Commercial and Health Advantage; autism/ABA are not covered for Medicaid (refer to local mental health center)

ActionProviders should consult plan documents for benefit limits and coverage specifics

ExceptionMedicaid: autism and ABA services not covered by the plan; refer to local mental health center

CGM and insulin pump policy

CGM & supplies preauthAll codes for continuous glucose monitors, insulin pumps, and associated supplies require preauthorization; effective 5/1/2023 for Medicaid, prior authorization is NOT required for CGMs and supplies for members with type I diabetes or diabetes in pregnancy/childbirth/puerperium

Insulin pumps

Policy Summary

Payermclaren health plan

PolicyService Codes Requiring Prior Authorization and Related Preauthorization Rules

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization from McLaren for listed services when required before rendering, except where per-code or product-specific exceptions apply.

SourceLink

On This Page

ALL of the following

Out-of-network ambulatory surgery center, outpatient facility, physician services, dialysis, pharmacy and specialty medications/injections under Health Advantage: Health Advantage preauthorization is not required (verify out-of-network benefits).

ALL of the following

Transplant services: cornea and kidney transplants for Medicaid generally do not require authorization unless performed during an inpatient hospital stay (inpatient authorization required); Health Advantage Transitional Care Program requires preauthorization.

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

Prior Authorization

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

Prior Authorization

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

Prior Authorization

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.)

Prior Authorization

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

Prior Authorization

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

Billing Rule

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

Note

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

Billing Rule

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

Prior Authorization

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)

Prior Authorization

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

Billing Rule

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

Note

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

Denial Risk

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

Insulin pumps and supplies continue to require prior authorization

ActionConsult plan documents for exceptions and coverage availability across lines of business

Home Care

Home care (Medicaid)First 24 billed home care visits per calendar year do not require prior authorization (effective 1/1/2020); additional visits require authorization

BillingVisits are billed on institutional claim types and revenue codes as specified in plan documents

ActionContact Customer Service to confirm visit counts and authorization requirements

Out-of-Network (OON) Services

OON services definitionOut-of-Network (OON) Services defined as Type of bill '83X', OON outpatient facility revenue codes (e.g., 0360-0362, 0367, 0369, 0481, 0490, 0499, 0790, 0799) and billed professional claims marked OON

Health AdvantageHealth Advantage preauthorization often not required for specified OON ambulatory/outpatient facility and physician services; verify benefits prior to service

ActionProviders should verify out-of-network benefits before services are rendered

Urgent Preauthorization Requests

Urgent designationRequests are considered urgent only when delay could jeopardize life/health, ability to regain maximum function, or cause severe unmanaged pain

ActionFollow expedited preauthorization process when criteria for urgent requests are met

ReferenceSee Urgent Preauthorization Requests definitions and preauthorization grid

Preauthorization

Preauthorization requirementPrior authorization must be obtained before service to confirm medical necessity per Provider Referral and Preauthorization Form and plan documents

Provider formsUse Provider Referral and Preauthorization Form as specified in plan materials

ContactCustomer Service: (888) 327-0671 for questions and confirmations

Buy & Bill Medicaid

Buy & Bill Medicaid notePhysicians administering carved-out C, J, S, and Q codes must bill Fee For Service (Medicaid only)

ImplicationAdministering physicians should submit claims to Medicaid FFS for carved-out codes rather than plan medical benefit billing

ReferenceSee Medical Pharmacy section for carved-out code examples (J0217, J0739, etc.)

vector genome per treatment

Vector genomes per treatmentVector genomes are expressed as pfu/ml per 0.1 ml in gene therapy product listings (used to calculate dose per treatment)

Example entrySpecialty medication entries list vector genome concentrations alongside product additions

ActionRefer to the specific product line entry for exact vector genome dosing per treatment

Removed code flag (duplicate reference)

Removed code flag - Q5128Q5128 (Cimerli) noted as Removed effective 4/1/2025

Change trackingCodes in the specialty medication list include 'added' and 'removed' dates; monitor these for billing and authorization changes

Update cadenceMedication/code list updated at least quarterly