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Michigan Medicaid - MDHHSMedicaid · Coverage · Claims & Billing · MI · Emergency Medicine, PsychiatryMedium impact

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

Act
by Sep 30, 2026
Effective date
Oct 1, 2026
Identified
Sep 2, 2026

Summary

Michigan Medicaid now covers and reimburses hospital-based Peer Recovery Coach (PRC) services for beneficiaries 18+ with Substance Use Disorders during ED visits or acute follow-up care. Services are billed using CPT H0038 in 15-minute increments with daily (8 units/2 hours) and monthly (40 units/10 hours) maximums. PRCs must be Medicaid-enrolled with NPI, MDHHS certified, and supervised by licensed clinical staff.

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What to do

by Sep 30, 2026 · 7 steps
01Billing 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).
02Verify 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.
03Implement SUD diagnosis requirement validation—all H0038 claims must include active SUD diagnosis code.
04Update 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.
05Billing 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.
06Create internal tracking for warm handoff compliance—flag claims where beneficiary requires ongoing SUD services for referral to PIHP/CMHSP.
07Note: 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.

Codes mentioned

H0038

Original notice

MMP 26-35: Coverage and Reimbursement of Hospital-Based Peer Recovery Coach (PRC) Services
michigan.gov · Always check the source before changing claims.
View original ↗

Related changes

See all Michigan Medicaid - MDHHS changes →
MSA 18-32MediumEffective Oct 1, 2018 · Provider BulletinBrowse every Michigan Medicaid - MDHHS change in the policy list

Related policy hubs

Michigan Medicaid - MDHHS policiesMI policy changesEmergency MedicinePsychiatryCode H0038

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