MMP 26-35: Coverage and Reimbursement of Hospital-Based Peer Recovery Coach (PRC) Services

By September 30, 2026: (1) Billing team must establish CPT H0038 billing capability in institutional claim processing system with 15-minute increment unit tracking and daily/monthly maximum enforcement (8 units/day, 40 units/month per beneficiary per provider). (2) Verify hospital is Medicaid-enrolled as Type 2 organization provider and update billing system to associate PRC individual (Type 1) NPIs as rendering providers on institutional claims. (3) Implement SUD diagnosis requirement validation—all H0038 claims must include active SUD diagnosis code. (4) Update claim submission workflow: PRC services from ED encounters or outpatient hospital follow-ups (including telemedicine) must be billed on institutional claims with PRC's individual NPI in Line Rendering field; ensure claims transitioning to inpatient admission are not separately billed outside DRG. (5) Billing staff must verify each PRC provider has current MDHHS certification, active NPI enrollment in CHAMPS, and appropriate clinical supervision documentation on file before processing claims. (6) Create internal tracking for warm handoff compliance—flag claims where beneficiary requires ongoing SUD services for referral to PIHP/CMHSP. Note: Claims will be denied if submitted by non-enrolled PRCs, without SUD diagnosis, exceeding daily/monthly limits, or for services outside ED/outpatient hospital settings or post-inpatient admission.