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Billing, Reimbursement Changes for Inpatient High-Cost Drug and Biologics (HCCAD)
Medicaid covers drugs and biologics administered in both inpatient and outpatient settings, however those administered in an inpatient setting are usually not reimbursed separately to hospitals. Instead, they are bundled into an All-Patient Refined Diagnosis Related Group (APR-DRG) payment.
Effective June 2, 2025, HCCAD will be carved out of the All-Patient Refined Diagnosis Related Group (APR-DRG) and eligible for separate reimbursement for the following:
Approved HCCAD List
- HEMGENIX
- ELEVIDYS
- SKYSONA
- LYFGENIA
- ZYNTEGLO
- ROCTAVIAN
- ZOLGENSMA
- CASGEVY
- KYMRIAH
- CARVYKTI
- ABECMA
- BREYANZI
- TECARTUS
- YESCARTA
Billing Requirements
- The hospital must bill HCCADs on a separate outpatient claim. Payment for the HCCAD must not be bundled with any other service.
- The associated inpatient or outpatient charges with the same date(s) of service are billed separately and remain part of the APR-DRG.
- The date of administration of the drug should be used on the HCCAD outpatient claim.
- Along with the members name, date(s) of service, and other required information, the HCCAD claim must include:
- The NDC qualifier of N4,
- The appropriate 11-digit National Drug Code (NDC) and corresponding HCPCS code for the drug; and,
- The number of units of the drug administered to the member that is covered by the claim; and,
- The NDC unit of measurement. There are five allowed values: F2, GR, ML, UN or ME.
- Submit an invoice of the actual acquisition cost of the drug.
Important Prior Authorization Note
Separate Prior Authorizations are required for both the inpatient admission and the HCCAD. The admission authorizations cover the hospital stay, while the HCCAD needs its own authorization for appropriate use and coverage.
If you have questions, please email PRSupport@BSWHealth.org.
Retroactive Enrollment Claims Reprocessing
Medicaid providers are experiencing significant challenges complying with Medicaid provider enrollment revalidation requirements and timelines. In response, HHSC is implementing provider enrollment revalidation flexibilities and requiring all Medicaid and CHIP payers to support these flexibilities. HHSC is taking action to extend revalidation due dates, reduce or eliminate enrollment gaps and require payers to support claims reprocessing efforts.
Retroactive Enrollment Periods & Claims Reprocessing
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