MLN Connects Newsletter for April 23, 2026

Federal Register link to the rule: Submit comments by June 15
Fact sheet
Press release
Technical workflows: Visual guides to assist with the technical implementation of the proposed National Council of Prescription Drug Programs standards and existing Payer-to-Payer and Prior Authorization Application Programming Interfaces
Proposed metrics summary: Detailed information regarding the new proposed reporting metrics
Summary of proposed provisions: High-level overview of the key proposals introduced in the rule
Town Hall presentation and recording (April 16, 2026)

Updated Behavioral Health Strategy

CMS announced its comprehensive Behavioral Health Strategy, a forward-looking initiative designed to promote timely, affordable, and high-value behavioral health services that enhance the health and well-being of all Americans. Grounded in 5 strategic pillars, the strategy emphasizes person-centered health promotion, early prevention, and integrative care that bridges physical and behavioral health with a special focus on children and adolescents. We’re committed to driving evidence-based care through value-based payment models, expanding access to innovative digital health technologies, and coordinating with states, providers, communities, and federal partners to ensure meaningful and lasting impact.

The strategy addresses these critical areas:

Mental health and wellness
Substance use disorder prevention, treatment, and recovery
Pain treatment and management
Care efficiencies
Special populations

Clinical Diagnostic Laboratories: Get Ready to Report Starting Next Week

Are you an independent laboratory, physician office laboratory, or hospital outreach laboratory that meets the definition of an applicable laboratory under the Clinical Laboratory Fee Schedule (CLFS)? If so, you must report data from May 1 – July 31, 2026, based on an updated data collection period of January 1 – June 30, 2025, including:

Applicable HCPCS codes
Associated private payor rates
Volume data

How do I report?

Review CLFS Data Collection System resources:
View the applicable HCPCS codes (ZIP)
Use the Data Reporting Template (ZIP)

More Information:

CLFS & PAMA Reporting and Resources webpage
CLFS (PDF) fact sheet
FAQs
Is My Lab an Applicable Lab? video

HETS Action Required: Enroll Third-Party Vendors for Access by May 11

Providers using third-party vendors to check Medicare beneficiary eligibility must now enroll these vendors with CMS for HIPAA Eligibility Transaction System (HETS) access by linking each vendor to your NPI.

If you haven’t already enrolled, visit HETS EDI: How to Enroll, and follow these steps:

Contact your vendor promptly
Obtain their unique ID
Use the ID to enroll and link the vendor to your NPI so they can continue submitting eligibility inquiries

Complete your enrollment by May 11 to ensure uninterrupted service. If your Medicare eligibility transactions fail with AAA error code "41" (no current, valid, relationship between the NPI and the third-party vendors), it may be due to incomplete enrollment. To prevent disruption to your services, finalize all enrollment requirements before May 11.

If you opt not to enroll, you may still check eligibility through your Medicare Administrative Contractor’s secure internet portal. After enrollment, you’ll receive monthly transaction volume reports for each vendor you enrolled.

Questions?

For report questions, contact your vendor
If you have concerns about your NPI being misused to check eligibility, contact mcare@cms.hhs.gov

Open Payments: Review Your Data by May 15

Covered recipients: You have until May 15, 2026, to review and dispute your 2025 Open Payments data before CMS publishes it in June. Review is voluntary but strongly encouraged.

Review and Dispute for Covered Recipients
Registration Quick Start Guides:
- Health Care Providers (PDF)
- Teaching Hospitals (PDF)

If you have questions, contact the Open Payments Help Desk at openpayments@cms.hhs.gov or 855-326-8366 (TTY: 844-649-2766).

Hospice Levels of Care & How to Bill for Service Intensity Add-On Payments

CMS posted a new video to educate hospices on service intensity add-on payments. This allows you to bill for additional registered nurse and social worker visits during the last 7 days of a patient’s life in addition to the standard daily reimbursement.

Visit the Hospice Center webpage for more information.

Hospitals: Accurately Report Allogeneic Hematopoietic Stem Cell Acquisition Costs

If you’re a subsection (d) hospital and you furnish inpatient allogeneic hematopoietic stem cell (Allo-HSC) transplants, you must accurately report Allo-HSC acquisition costs on your Medicare Cost Report:

Use Form CMS-2552-10, Worksheet D-6 from the Provider Reimbursement Manual, Part 2 (PDF)
Only include charges for the Medicare recipient or expected recipient in your hospital
Maintain an itemized statement that identifies all costs defined in 412.113(e)(2)

You must keep records for each patient receiving Allo-HSC acquisition services (donor or recipient). For all donor sources, you must identify the prospective recipient, recipient identifier, and MBI for Medicare patients.

If you perform Allo-HSC acquisition services for another hospital, National Marrow Donor Program, or similar organization, you must seek reimbursement from them. Don’t include the associated charge on Worksheet D-6. Medicare only pays for services you furnish to Medicare patients.

More Information:

Medicare Claims Processing Manual, Chapter 3 (PDF), section 90.3.1.A.2
FY 2021 Inpatient Prospective Payment System final rule
Further Consolidated Appropriations Act, 2020, Division N, Title 1, Section 108

Compliance

Lower Limb Orthoses: Prevent Claim Denials

In 2024, the improper payment rate for lower limb orthoses was 35.2%, with a projected improper payment amount of $91.2 M. Learn how to bill correctly for these services. Review the Lower Limb Orthoses provider compliance tip for more information, including:

Billing codes and criteria
Denial reasons and how to prevent them
Coverage and payments
Documentation requirements
Resources

Claims, Pricers & Codes

Vaccine Coding for Institutional Claims: Reporting Condition Code A6

CMS updated the Medicare Claims Processing Manual, Chapter 10 (PDF), Section 10.2.1. You must report condition code A6 on institutional claims when diagnosis code Z23 is required.

See the instruction to your Medicare Administrative Contractor (PDF).

HCPCS Application Summaries & Coding Determinations: Drugs & Biologicals

CMS published the 2026 HCPCS Application Summary for Quarter 1, 2026 Drugs and Biologicals. Visit the HCPCS Level II Coding Decisions webpage for more information.

Events

HCPCS Public Meeting – June 1–2

Monday, June 1 and Tuesday, June 2 from 9 am – 5 pm ET

Attend a hybrid public meeting for the first biannual 2026 HCPCS coding cycle. Visit HCPCS Level II Public Meetings for more information, including: 

Meeting materials 
Guidelines

MLN Matters® Articles

Low-Volume Hospital Payment Adjustment & the Medicare-Dependent Hospital Program: FY 2026 Extensions

Learn about new extensions (PDF):

The Consolidated Appropriations Act, 2026 extended through December 31, 2026:
- Temporary changes for the low-volume hospital payment adjustment policies
- Medicare-Dependent Hospital Program
The deadline to submit qualification or verification for the low-volume hospital payment adjustment for FY 2026 discharges is April 17, 2026
Your Medicare Administrative Contractor will apply the low-volume hospital payment adjustment prospectively for qualifying providers who submit qualification or verification after April 17, 2026

Publications & Multimedia

Clinical Laboratory Fee Schedule Data Collection & Reporting Webinar Recording

CMS posted materials from the April webinar:

Presentation (PDF)
Recording: Passcode =8Jwys2*

Medicare Preventive Services – Revised

Learn what’s changed:

Annual wellness visit: Updated description for HCPCS code G0136, effective January 1, 2026
Medicare Diabetes Prevention Program:
- Added HCPCS code G9871 to the list of codes that can be billed with modifier 76, effective January 1, 2026
- Removed the service frequency limit for patients, effective January 1, 2026
Sexually transmitted infection (STI) screening and high intensity behavioral counseling to prevent STIs: Added CPT code 87494, effective January 1, 2026

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