Michigan Medical Billing and Payer Rules

Timely Filing in Michigan

Michigan Surprise Billing vs the Federal NSA

Insured plans and state or local government plans follow Michigan's surprise billing statute for the services it covers. Self-funded private employer plans follow the federal No Surprises Act and federal IDR. We confirm plan type before filing either dispute.

Major Payers

How Does Michigan Medicaid Billing Work?

Michigan Medicaid is run by the Michigan Department of Health and Human Services (MDHHS). Fee-for-service claims go to MDHHS through its claims system, the Community Health Automated Medicaid Processing System (CHAMPS), and claims for patients enrolled in a Medicaid health plan go to that plan. The first question on any Michigan Medicaid account is which of the two was responsible on the date of service.

The Medicaid Provider Manual (version dated October 1, 2026) states the split plainly. MDHHS pays Medicaid Health Plans (MHPs) a monthly capitation rate, and the manual says providers may not bill fee-for-service or the beneficiary for services the MHP covers, and may not bill the MHP for services covered by fee-for-service.

The Healthy Michigan Plan is the state's Medicaid expansion for low-income adults. CMS's managed care tables list it as a comprehensive managed care program that began on April 1, 2014 under a Section 1115 demonstration waiver. The tables also list a Comprehensive Health Care Program in operation since July 1, 1997.

Facility claims go on the UB-04 and professional claims on the CMS-1500. Our Medicaid payer guide covers the national rules.

What Is the Michigan Medicaid Timely Filing Limit?

A Michigan Medicaid fee-for-service claim must be received and assigned a Transaction Control Number (TCN) by MDHHS within 12 months of the date of service. That is section 11.3 of the General Information for Providers chapter of the Medicaid Provider Manual, version dated October 1, 2026. The TCN is an 18-digit number on the remittance advice.

The manual defines the date of service. For claims on the institutional format and for MHPs it is the "To" or "Through" date on the claim, and for all other providers it is the date the service was rendered. For a hospital stay that crosses a month end, the clock starts from the end of the span.

Resubmitting does not keep an old claim alive. The manual says all claims must be resolved within one year of the date of service, that continuous activity through multiple submissions is no longer needed, and that claim replacements requesting additional payment must meet an exception to be considered beyond one year. The bulletin that created the policy, MSA 16-37, cites 42 CFR 424.44 as its basis.

The manual lists these exceptions to the limit:

• Department administrative error, including wrong written instructions from MDHHS staff.
• Eligibility or authorization established retroactively more than 12 months after the date of service.
• Eligibility established retroactively less than 12 months after the date of service: claims are accepted up to six months after the retroactive eligibility determination date, with "timely filing" in the claim comment.
• A court or MOAHR administrative law judge ordered payment.
• Medicare processing was delayed: Medicaid must be billed within 120 days of the Medicare payment, rejection or recovery.
• A provider returning an overpayment, through a replacement claim.
• A primary insurer took back payment after the limit passed: the claim must be submitted within 120 days of the insurer's letter or remit date, with a copy of the letter or EOB.

The manual says retroactive provider enrollment is not an exception. For the first two exceptions the provider contacts the local MDHHS office, a caseworker submits form MSA-1038 (the Request for Exception to the Twelve-Month Billing Limitation), and once approved the provider bills through CHAMPS with "MSA-1038 approval on file" in the comment section.

Example (illustrative dates): a patient is discharged on March 10, 2026, so the facility claim's "Through" date is March 10, 2026. The claim must have a TCN by March 10, 2027, and our team sets an earlier internal deadline. A replacement filed after that date needs one of the exceptions above and its proof.

Who Is the Medicare MAC for Michigan?

The Medicare Administrative Contractor (MAC) for Michigan Part A and Part B claims is Wisconsin Physicians Service Government Health Administrators (WPS), Jurisdiction 8. CMS's list of MACs by state shows Jurisdiction 8 as Indiana and Michigan, so a hospital in Detroit and one in Indianapolis send claims to the same contractor.

A MAC processes Medicare fee-for-service claims, handles provider enrollment and runs the first level of appeal. Medicare's filing limit is one calendar year after the date of service under 42 CFR 424.44(a)(1), the same period Michigan Medicaid uses. When a patient has both, the Medicare claim goes first, and Medicaid must be billed within 120 days of the Medicare payment or rejection.

The same CMS table lists other contractors for Michigan: CGS Administrators for DME claims (Jurisdiction B) and National Government Services for home health and hospice. Confirm your contractor on the CMS page. Our Medicare guide covers claim, appeal and enrollment steps.

What Is Michigan's Prompt Pay Law for Insurers?

Under MCL 500.2006(8)(a), a Michigan health plan must pay a clean claim within 45 days after it receives the claim, and a clean claim not paid within 45 days bears simple interest at 12% per annum. This applies to claims from health professionals, health facilities, home health care providers and durable medical equipment providers. The text comes from section 2006 of the Insurance Code of 1956 (Act 218 of 1956).

The statute sets a back-and-forth. The plan must notify the provider within 30 days after receipt of all known reasons the claim is not clean, under subsection (8)(b). The provider then has 45 days, or longer if the plan allows, to correct the defects, and the 45-day payment period is tolled from the date the notice is received until the plan receives the response, under (8)(c). If the response does not fix the claim, the plan must send an adverse determination with reasons inside the 45-day period, excluding the tolled time.

Timing also binds the provider. A claim is clean only if billed within 1 year after the date of service or discharge, under (8)(f), and the provider may not resubmit the same claim before the 45-day period has passed, under (8)(g). Subsection (14)(a) defines a clean claim by items such as provider and patient identification, date and place of service, covered services for an eligible person, prior authorization information and generally accepted coding. Under (10), a plan must pay the payable services on a claim and may not deny the whole claim over defects in others.

A provider that believes a plan violated the payment procedures may file a complaint with the director of insurance on an approved form, under (12), and the director may fine a plan up to $1,000 per violation, capped at $10,000 in total, under (13). The statute says subsections (7) to (14) do not apply to Medicaid claims covered under section 111i of the social welfare act, and the definition of health plan excludes administrative-services-only and cost-plus arrangements. Self-funded employer plans therefore need a different lever, usually the plan document and federal rules. Our prompt pay laws by state guide compares the states.

Does Michigan Have Its Own Surprise Billing Law?

Yes. Michigan's surprise billing law is Article 18 of the Public Health Code, MCL 333.24501 to 333.24517, added by 2020 PA 234 and effective October 22, 2020, and CMS treats it as a specified state law that sets the out-of-network rate for the services it covers. Everything else goes to federal IDR. CMS wrote this in its Michigan enforcement letter dated July 20, 2023.

Under MCL 333.24507, a nonparticipating provider must accept from the patient's carrier, as payment in full, the greater of two amounts: the median amount the carrier negotiated for the region and provider specialty, or 150% of the Medicare fee-for-service fee schedule, excluding in-network cost sharing. The provider must submit the claim to the carrier within 60 days after the date of service, and the carrier must pay within 60 days after receiving it. The provider may not collect anything beyond the in-network coinsurance, copayment or deductible.

Section 24507(1) covers covered emergency services at any facility; covered nonemergency services at a participating facility where the patient could not choose a participating provider or lacked the required disclosure; and services during a hospital stay following admission within 72 hours of an emergency room service. "Carrier" includes insurers and HMOs, and the self-funded plans of the state or a local government. The definition of carrier does not name self-funded private employer plans.

For scheduled nonemergency care, section 24509 requires a signed disclosure. A hospital, surgical outpatient facility, skilled nursing facility, laboratory or imaging center must give it at least 14 days before the service, or within 14 days if the service is scheduled inside 14 days. A physician's office or other outpatient setting must give it at the first contact. The provider must keep a copy for at least 7 years and give a good-faith estimate. A provider that fails to give the disclosure is paid under the same median-or-150% rule.

Section 24511 adds a path for complicating factors on emergency care. The provider files a claim for more than the section 24507 amount with clinical documentation and the highlighted medical record. The carrier has 30 days to either pay an additional 25% of the median negotiated amount or deny. After a denial, the provider can ask the Department of Insurance and Financial Services (DIFS) for binding arbitration, the carrier has 30 days after notice to confirm its denial or offer a different payment, and the arbitrator decides within 45 days of receiving the parties' documents. The parties split the arbitration costs in half.

Under 45 CFR 149.510, either party can start a 30-business-day open negotiation period within 30 business days of the initial payment or denial, and federal IDR must be started within 4 business days after open negotiation ends. Our state surprise billing laws guide explains how the state and federal paths fit together.

Which Michigan Agency Enforces Which Surprise Billing Rule?

Two state agencies share enforcement, and CMS fills the gaps. According to the CMS letter, DIFS enforces the No Surprises Act provisions that apply to health insurance issuers, and the Department of Licensing and Regulatory Affairs (LARA) enforces MCL 333.24507 and 333.24509 against providers.

CMS enforces some federal provisions directly in Michigan: DIFS told CMS it does not intend to enforce the federal IDR sections against issuers, and MDHHS does not intend to enforce the air ambulance provisions. CMS also considers MCL 333.24507 to give the same protection as federal section 2799B-1 on provider balance billing, so CMS does not enforce 2799B-1 against Michigan providers.

Which Payers Matter Most in Michigan?

The payers we can source for a Michigan hospital or ER group are Medicare through WPS, Michigan Medicaid fee-for-service through CHAMPS, and the Medicaid health plans. CMS's 2021 managed care table lists these plans in the Healthy Michigan Plan and Comprehensive Health Care Program: Aetna Better Health of Michigan, Blue Cross Complete of Michigan, HAP Empowered, McLaren Health Plan, Meridian Health Plan of Michigan, Molina Healthcare of Michigan, Priority Health Choice, Total Health Care, UnitedHealthcare Community Plan and Upper Peninsula Health Plan.

That list is a 2021 snapshot, so confirm current plans with MDHHS before loading payer IDs. This page cites no DIFS market share data, so we do not rank commercial payers. We have guides for Blue Cross Blue Shield and Molina Healthcare.

How We Handle Billing in Michigan

For Michigan clients we sort every out-of-network account by plan type first, because that decides whether the dispute goes through Michigan's statute or federal IDR. Claims go out within 24 hours of charge entry and denials are worked within 48 hours. Medicaid dates are tracked on the account by the "To" or "Through" rule, not in a spreadsheet. To talk through your Michigan payer mix, book a call.