Medicaid provider update: High-cost Medicaid drug billing

Billing requirements for Medicaid-covered drugs

UPMC for You and UPMC Community HealthChoices are committed to complying with Medicaid billing standards for high-cost drugs administered and billed by providers for outlier payment or single case agreements. In alignment with the Department of Human Services (DHS) and CMS Medicaid Drug Rebate Program, UPMC for You and UPMC Community HealthChoices require the following for drug rebate reliability:

               General billing guidelines

• Claims must be submitted using 837 Professional or 837 Institutional formats.
• Drugs billed via HCPCS codes (e.g., J-codes) must also adhere to the following requirements:
  • Accurate National Drug Codes (NDCs) and NDC units dispensed
  • Include corresponding J-code
  • The drug appears on a single claim line, with no other services
  • Drug administration is billed separately
  • All other services must be billed on a separate claim
  • A 340B provider can administer both 340B and non-340B drugs. 340B-purchased drugs must include the UD modifier. Non-340B-purchased drugs should not include a UD modifier.
  • 340B covered entities cannot dispense or administer 340B purchased drugs for any drug included in Appendix 18B of the Managed Care Organization (MCO)Agreement.

Special guidance: CMS Cell and Gene Therapy (CGT) Access Model for Sickle Cell Disease

• For therapies like Lyfgenia and Casgevy, the following conditions apply:
  • Providers must be registered with the Center for International Blood & Marrow Transplant Research (CIBMTR) and participate in a CMS-specified study.
  • These therapies are excluded from 340B purchasing under the model (full list available in Appendix 18B of the MCO Agreement).
  • 340B-covered entities must use non-340B inventory for Medicaid patients receiving these therapies

Please note that it is the responsibility of the provider billing team to appropriately bill for services rendered. Accurate claims submission is essential for timely payment and compliance with federal rebate programs.

References: Managed Care Operations Memorandum OPS# 10/2013-012 and OPS# 05/2013-006, and Medical Assistance Bulletin MAB2022122201