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 (CMS) News
Billing Medicare Part B for Insulin with New Limits on Patient Monthly Coinsurance – Revised
The Centers for Medicare & Medicaid Services (CMS) added additional information about what type of insulin and insulin pumps are covered under Medicare Part B. The updates can be viewed in the new Medicare Learning Network (MLN) Fact Sheet: Billing Medicare Part B for Insulin with New Limits on Patient Monthly Coinsurance
New Webinars
The following webinars are open for registration. Visit the Live Events listed on the Wisconsin Physicians Service (WPS) webpage to learn more and register. Questions can be submitted prior to events as part of the registration process. They use Training Indicators to help determine which webinars are applicable.
Provider Enrollment Basics
4/14/2026 11:00 am – 12:00 pm CT (12:00 – 1:00 pm ET)
Becoming a Medicare provider can be overwhelming. This session will:
- Provide an overview of the provider enrollment process
- Share general eligibility and application requirements
- Explain the provider enrollment application submission process
- Cover tips and tricks to avoid common mistakes
Targeted Probe and Educate (TPE) Review for Cardiac Rehabilitation Services
4/16/2026 1:00 – 1:45 pm CT (2:00 – 2:45 pm ET)
Cardiac rehabilitation services have been highlighted as a significant risk, with claims at high financial risk due to above-average billing and dollars paid in the J8 jurisdiction. This session will focus on the coverage criteria and documentation required to ensure these services are payable by Medicare. This session covers Current Procedural Terminology (CPT) code 93798 information, including:
- What is needed to meet Medicare's specific requirements for cardiac rehab services
- How to properly document and substantiate claims to prevent denials
- Why cardiac rehabilitation services are a significant focus for TPE reviews
McLaren Health Plan News
McLaren Health Plan announced new upcoming preauthorization changes for Medicare, effective June 1, 2026. The Medicare authorization changes document is available online at: mclarenhealthplan.org > Providers.
McLaren Health Plan also posted updated documents for the Primary Care Physician (PCP) Incentive Program and Mammogram Screening Incentive Program. Each was updated to reflect a new incentive for breast cancer screening of members aged 42–49 (attached and online – links below).
- PCP-Incentive-Program.pdf
- Mammogram-Screening-Incentive.pdf
- Refer to the MHP Provider Manual to navigate administrative processes and covered services.
For questions, contact McLaren Health Plan Customer Service at 888-327-0671.
Health Alliance Plan of Michigan (HAP) News
Gene Therapy Prior Authorization
Health Alliance Plan of Michigan (HAP) released a reminder that all gene therapy requires prior authorization for all HAP Commercial and Medicare Advantage members.
Additional prior authorization requirements can be found online by logging in at hap.org, selecting Quick Links, Procedure Reference Lists; and Services that require Prior Authorization list.
Update - Matrix Medical Network & Advantmed Partnership for No Cost In-Home Health Visits and Annual Wellness Visits
During 2026, HAP is partnering with Matrix Medical Network (Matrix) & Advantmed to offer a no cost in-home health assessment with a nurse practitioner. This unique health service is for select HAP Medicare Advantage members. Eligible members will receive one in-home health assessment per year through either Matrix Medical Network or Advantmed. Members can only receive one visit per year.
Matrix and Advantmed in-home health visits are:
- Meant to enhance and supplement a member’s relationship with their primary care physician
- Designed to be a comprehensive health assessment to address gaps in care related to: risk adjustment, quality measures and care management
Matrix and Advantmed in-home health visits are not:
- A replacement for an annual wellness visit (AWV)/or physical with a PCP
The in-home health assessment and wellness visits may include:
- Brief exams, including vital signs
- Active, inactive, and chronic medical diagnoses with associated medication
- Functional status and fall risk assessment
- Personal and social history of drug, tobacco, and alcohol screenings
- Diabetes and cancer assessments
- Depression screening
- Clinical assessment of the patient with management plan
- Preventive and chronic disease case recommendations
- Case management referral (if applicable)
After an in-home health assessment visit, Matrix or Advantmed will send a summary of the results to the member and their primary care physician. If you have any questions about this partnership, please email providernetwork@hap.org (Be sure to put “Matrix” or “Advantmed” in the subject line).
If you have questions about the assessment and process, please contact: Matrix Support: memberfeedback@matrixhealth.net or (877) 561-7335 Monday – Friday, 8 a.m. to 6 p.m. Advantmed Support: (800) 371-8852, Monday – Friday, 8 a.m. to 6 p.m.
Blue Cross Blue Shield of Michigan (BCBSM) News
Coding Corner: Provide clear, accurate documentation for alcohol use disorder
Alcohol use disorder is often documented using vague or inconsistent language, which can prevent accurate code assignment or require clarification. Clear, specific documentation ensures the medical record accurately reflects the patient’s condition and the care provided.
Use clear diagnostic terms: If an alcohol-related disorder is present, document the diagnosis using established terminology such as:
- Alcohol use
- Alcohol abuse
- Alcohol dependence
Social history alone does not establish a diagnosis. Statements such as “drinks daily” or “binge drinks on weekends” describe behavior but do not support code assignment unless a formal diagnosis is documented.
Be clear about current status: Status clarifies whether the condition is active and how it affects care. If alcohol abuse or dependence is diagnosed, include the current status when appropriate, such as:
- Continuous
- Episodic
- In early remission
- In sustained remission
- With intoxication
- With withdrawal
- With alcohol-induced condition
“History of” vs. active condition: Document “history of alcohol dependence” only if the condition is resolved and no longer being treated or monitored. If the patient is in remission or continues to be monitored, document that clearly rather than using “history of” (for example: “alcohol dependence in sustained remission”).
During the visit: When alcohol use disorder appears in the problem list or past medical history, document how it is addressed when clinically relevant, including its effect on other conditions or care decisions.
Examples of clear documentation
- Alcohol dependence, continuous. Counseling provided and labs ordered.
- Alcohol dependence in sustained remission. Continuing outpatient support.
- Alcohol abuse with withdrawal symptoms. Evaluated and managed during visit.
Time-saving tips for authorizations: Fewer calls, faster answers
Blue Cross Blue Shield of Michigan (BCBSM) offers time saving tips on three common calls on prior authorizations they receive and their recommendations for getting quick answers.
To check whether a service needs authorization
Use Availity Essentials™. In most cases, the Authorization and Referrals tool will tell you whether you need to request prior authorization for a particular member. Alternatively, refer to the document Procedure codes for which providers must request prior authorization on authorizations.bcbsm.com.
To check the status of an authorization request
Use the e-referral system, available at any time. Allow 48 hours from submission for the status to update. If submitted through another designated vendor, access the application through Availity.
To report a change to a service date
Confirm whether the new date falls within the originally approved date span. If so, it will not affect claims payment or coverage.
Resources:
- For information on setting up and maintaining the e-referral system, refer to Availity Essentials administrators: Set up and maintain the e-referral tool.
- For more details about using the Availity Authorizations and Referrals tool, refer to the document Determining prior authorization requirements for members.
- The Provider Prior Authorizations Training Tools page contains details about online self-paced learning for prior authorization programs.
For further questions or assistance, contact Dara Barrera, MSMS Director of Health Quality, Equity and Technology at djbarrera@msms.org or 517-336-5770.