Site of Service program (ASC vs outpatient hospital authorization requirements)
Customize your policy alerts
Sign up for all mclaren health plan policy alerts
Know when mclaren health plan releases new policies or updates existing guidance.
Monitor payer policy activity
Defines McLaren Health Plan's Site of Service program requiring certain surgical procedures to be performed in an Ambulatory Surgical Center (ASC) without authorization and requiring preauthorization and medical necessity review if performed in an outpatient hospital setting; applies to McLaren Health Plan Medicaid and Community/Commercial members and their providers.
McLaren Health Plan is implementing a Site of Service program effective 4/1/25 that lists specific procedure codes that are allowable without authorization in an ASC but require preauthorization if performed in an outpatient hospital setting.
McLaren Health Plan is partnering with J & B Medical as an exclusive vendor for incontinence, ostomy, and urology supplies for Medicaid effective 4/1/25.
Authorization requirement updates, changes, and clarifications will be published quarterly with effective dates of January 1, April 1, July 1, and October 1.
Site of Service Coverage Rules
Site-based coverage criteria
Covered when meeting the site-of-service rules below:
ALL of the following
- ASC: If the listed procedure is performed in an Ambulatory Surgical Center (ASC), authorization is not required per the Site of Service program.
- Outpatient hospital: If the listed procedure is requested or performed in the outpatient hospital setting, preauthorization and medical necessity review are required.
- Denial risk: If the outpatient hospital setting procedure is not preauthorized, the claim will be denied.
ALL of the following
- The Site of Service program lists specific CPT/service codes for cataract surgery, colonoscopy, eye and ocular adnexa, ophthalmologic procedures, and upper gastrointestinal endoscopy that are allowable without authorization in an ASC (see coding section for full code list).
ALL of the following
- Program applies to McLaren Health Plan Medicaid and Community/Commercial membership and is effective 4/1/25.
Procedure Codes and Authorization Status
Provider Requirements and Notices
Preauthorization required for listed services performed in outpatient hospital settings — claims denied if not preauthorized
These procedure codes are included in McLaren Health Plan’s Site of Service program and are allowable without authorization when performed in an Ambulatory Surgical Center (ASC); however, if the same services are requested or performed in an outpatient hospital setting they require preauthorization and medical necessity review. Claims for these listed services performed in the outpatient hospital setting will be denied if not preauthorized.
- Applies to McLaren Health Plan Medicaid and Community/Commercial members.
- Examples of included codes: 66821, 66982, 66984, 66987, 66988, 45378, 45380, 45384, 45385, 65710, 65820, 66250, 66710, 66711, 66825, 66986, 67010, 67041, 67042, 67105, 67108, 67113, 67840, 68110, 68115, 68320, 68720, 68815, 65426, 65730, 65855, 66170, 66761, 67028, 67036, 67040, 67228, 67311, 67312, 43235, 43239, 43249
Quarterly authorization updates and effective dates (Jan/Apr/Jul/Oct)
Authorization requirement updates, changes, and clarifications are published quarterly on the McLaren Health Plan provider website and become effective in January, April, July, and October of each year; providers should consult the online list of Service Codes Requiring Preauthorization for the effective date of any change.
- Updates become effective on January 1, April 1, July 1, or October 1 of each year.
- The current list is available at McLarenHealthPlan.org > Providers > Medical Management and Authorization > Referral and Authorization Guidelines.
- Contact Provider Relations at 888-327-0671 (TTY: 711) with questions.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.