Payer Updates

Payer Updates

For a curated summary of the latest payer updates impacting Northern Michigan physician offices, grouped by payer then category, please see below:

BCBSM and BCN

  • Oncology: OncoHealth medical benefit drug list expanding on June 1, 2025. SOURCE
  • All Authorized Services: Link to procedure code table indicating whether prior authorization is needed. SOURCE
  • All Ambulatory Authorizations/Medicare Advantage: Patients with new Blue Cross Medicare Advantage coverage need continuity of care questions addressed when placing an authorization. SOURCE

Health Alliance Plan

All Authorizations/Health Alliance Plan: Submit HAP Authorizations with the NPI and TIN Site Billed on the Claim: HAP requires the authorization location (NPI/TIN) match the service location billed on a claim. Claims will deny if the authorization and claims NPIs and TINs do not match. Appeals for denials will also be upheld. 

Although this issue is fixable at the claim level, it takes multiple administrative steps. If you encounter any of these types of denials, please contact Laura Stuursma for the resolution workflow.

McLaren

Eye and GI Procedures/McLaren Medicaid and Commercial: Beginning April 1, 2025, McLaren will require prior authorizations on eye procedures, colonoscopies, and EGDs when provided as facility outpatient. SOURCE

Priority Health

Authorization Appeal: Effective June 2, 2025, no appeals are allowed on denied authorizations: Outpatient, DME, Home Health, Elective Inpatient, Behavioral Health. SOURCE