The Michigan State Medical Society (MSMS) Health Care Delivery Department receives news from several of Michigan’s health plans and insurers related to policies, programs, and education opportunities. Below are some updates which may be of interest to physicians and other health care team members.
Centers for Medicare & Medicaid Services News
2026 CMS Interoperability Standards & Prior Authorization Proposed Rule Resources
The Centers for Medicare & Medicaid Services (CMS) has issued its 2026 Interoperability Standards and Prior Authorization for Drugs proposed rule (CMS-0062-P). The stated intent is to make prior authorization more efficient, transparent, and reliable for patients and providers. Building on earlier interoperability rules from 2020 and 2024, the proposal extends electronic prior authorization requirements to prescription drugs, requiring impacted payers to adopt faster decision timelines, enhance transparency, and support standardized APIs. It also calls for updated health IT standards and reporting on API use. In parallel, under the Health Insurance Portability and Accountability Act (HIPAA), the Department of Health and Human Services (HHS) proposes adopting Fast Healthcare Interoperability Resources (FHIR)-based standards for prior authorization transactions across all HIPAA-covered entities. Public comments on the proposed rule are open through June 15, 2026. For more information and fact sheets: 2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule (CMS-0062-P)
Updated Behavioral Health Strategy
CMS announced its comprehensive Behavioral Health Strategy, which is intended to promote timely, affordable, and high-value behavioral health services by emphasizing person-centered health promotion, early prevention, and integrative care that bridges physical and behavioral health with a special focus on children and adolescents. CMS states that they are committed to driving evidence-based care through value-based payment models, expanding access to innovative digital health technologies, and coordinating with states, providers, communities, and federal partners to ensure meaningful and lasting impact.
The strategy addresses these critical areas:
- Mental health and wellness
- Substance use disorder prevention, treatment, and recovery
- Pain treatment and management
- Care efficiencies
- Special populations
McLaren Health Plan News
FQHC, RHC, THC Reimbursement Recoupment
Following a post-adjudication audit, McLaren Health Plan identified claims that were reimbursed inconsistently with Michigan Department of Health and Human Services (MDHHS) guidelines, prompting a one-time reprocessing and recovery initiative. This update outlines how reimbursement policies have evolved—particularly the shift from fee-for-service to per diem payment structures for FQHCs, RHCs, and THCs—and clarifies how claims will be evaluated moving forward. Providers should be aware that McLaren will begin outreach and recoupment efforts in mid-June 2026, with adjustments based on established Medicaid billing rules and contractual obligations. View the full information on the website at: mclarenhealthplan.org > Providers > Claim Payment Initiatives.
Health Alliance Plan News
Professional Claims with Billed Amounts Exceeding $99,999.99
According to the Health Alliance Plan (HAP), follow the guidelines below when submitting professional claims with amounts exceeding $99,999.99 for your HAP Commercial and Medicare Advantage patients:
- Professional Electronic Claims
- Professional electronic claims (837P) cannot contain a billed amount greater than $99,999.99 on any single claim line due to transaction standards.
- Claims that exceed this limit will be rejected.
- If the total charges for a service are more than $99,999.99, the charges must be split and submitted on multiple claims, regardless of whether the services occurred on one date or multiple dates.
- Each claim submitted must remain under the $99,999.99 limit.
- Electronic Submission with Multiple Related Claims
- Providers must include a claim note on each claim indicating the claim sequence number and the total combined billed amount for all related claims. For example: Claim 1 of 3; Total billed amount for all claims = $125,000
- To prevent duplicate claim denials, the charges and/or quantities billed on each claim must differ and accurately reflect the portion of the total charge being billed.
- Billing Drugs or Biologicals Across Multiple Claims
- Providers must ensure the quantity billed correctly reflects the amount administered and that applicable HCPCS modifiers (such as those for discarded drug amounts) are used appropriately. Quantities must align with the HCPCS unit definition.
- Providers are responsible for verifying that quantities, charges, and supporting documentation are accurate prior to submission, as reimbursement on any single claim line cannot exceed $99,999.99.
Update - Medical Record Review Projects
HAP partners with vendors, including Optum/Episource, LLC and Cognisight, to conduct ongoing medical record review projects, with provider offices contacted directly if selected. Notifications will include required member lists, submission instructions, and due dates, and some offices may be contacted multiple times due to different regulatory requirements or dates of service. Providers who are not contacted do not need to take action; however, failure to respond when contacted may result in recovery of paid claims in accordance with HAP policy and contracts. HAP notes it will work with providers to minimize disruption to patient care and encourages outreach to Provider Services with any questions
Meridian Health Plan News
Provider Satisfaction Survey Coming Soon
Meridian Health Plan announced it was launching its annual provider satisfaction survey in April 2026. This survey plays a key role in shaping Meridian’s improvement initiatives, and provider feedback is essential to ensuring that priority issues are addressed. Providers are encouraged to complete the survey and take the opportunity to share their experiences to help improve interactions and processes moving forward.
Blue Cross Blue Shield of Michigan/Blue Care Network News
Reminder: Regularly Review Your Organization’s Access Permissions in Availity Essentials
Providers are reminded to regularly review access permissions within Availity Essentials to help safeguard protected health information. Administrators should update employee and vendor access—such as for billing or credentialing services—at least every three months, or more frequently for larger organizations with higher turnover. In addition to removing access for former users, administrators can also manage permissions for specific tools within the platform, including e-referral, provider data management, and enrollment services, to ensure appropriate and secure system use. See full information and resources in the BCN Provider News: May/June 2026
Advanced Practice Providers are Now Eligible for Health e-Blue
Advanced practice providers (APPs), including nurse practitioners and physician assistants, are now eligible for access to Health e-Blue℠ tools for Blue Cross Blue Shield of Michigan commercial plans and Medicare Plus Blue, effective April 1, 2026. Administrators using Availity Essentials can now submit access requests on behalf of APPs by following the required setup steps; previously denied requests must be withdrawn and resubmitted. This update does not apply to Blue Care Network, and support is available through Availity or BCBSM for any access issues. View more in the BCBSM Value Parentships Update April 2026
For MSMS members who have questions or need assistance regarding billing and reimbursement issues, please contact Dara Barrera, Director, Health Quality, Equity and Technology at djbarrera@msms.org or 517-336-5770.