Summary
Effective for dates of service on and after April 1, 2019, Michigan Medicaid added J1322 (Vimizim) to the Medicaid Health Plan Carve-out list, and coverage of this medication requires prior authorization. The July 2019 Michigan Medicaid Provider Manual updates also added prior authorization codes B4100, B4105 and E0776 for enteral nutrition, added billing rules for certified nurse midwives, and included enrollment and hospital settlement changes, along with many technical changes and clarifications.
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What to do
Action · 10 steps
01Already effective April 1, 2019: For J1322 (Vimizim), which was added to the Medicaid Health Plan Carve-out list, get prior authorization, because coverage of this medication requires prior authorization.
02Billing team: For enteral nutrition, whether administered orally (section 2.13.A) or by tube (section 2.13.B), the PA requirements now include HCPCS B4100, B4105 and E0776.
03For osteogenesis stimulators, PA is required and evaluated case by case, and the rental is approved for three months at a time for up to a maximum of ten months.
04For rental beyond the initial three months, submit a new MSA-1653-B along with physician documentation establishing the medical reason(s) for continued need.
05Accessories needed to use the unit, or a replacement stimulator after purchase, require prior authorization, and the manufacturer's warranty must be exhausted before requesting a replacement.
06For certified nurse midwife professional claims, include the CNM's NPI in the Rendering Provider field and the supervising or collaborating physician in the Supervising Provider field as applicable.
07When a provider has an excess patient pay amount and has been billing Medicaid, return any overpayments made by MDHHS using a replacement claim or a void/cancel claim.
08Hospitals participating in the Medicaid FFS 340B program must continue to bill 340B actual acquisition cost and all applicable modifiers.
09Providers must notify MDHHS within 35 days of any change to their enrollment information.
10Nursing facilities must complete the online Level of Care Determination under the provider's NPI prior to the start of Medicaid reimbursable services.
Codes mentioned
J1322B4100B4105E0776
Original notice
MSA 19-15
michigan.gov · Always check the source before changing claims.
Related changes
See all Michigan Medicaid - MDHHS changes →MMP 24-30: Updates to the MDHHS Medicaid Provider ManualMediumEffective Oct 1, 2024 · Medical PolicyMSA 18-16MediumEffective Jul 1, 2018 · Provider BulletinMSA 19-01MediumEffective Jan 1, 2019 · Provider BulletinMSA 20-25HighEffective Mar 1, 2020 · Provider BulletinBrowse every Michigan Medicaid - MDHHS change in the policy list