Date: May 23, 2025
Attention: All Providers
Effective Date: June 2, 2025
Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers about inpatient admission and billing updates in regard to High-Cost Clinician-Administered Drugs (HCCAD). These changes are designed to streamline the reimbursement process and ensure compliance with Medicaid guidelines.
Key Details
While Medicaid covers drugs and biologics administered in both inpatient and outpatient settings, those administered in an inpatient setting are usually not reimbursed separately to hospitals. Instead, they are bundled into a Diagnosis Related Group (DRG) payment. Effective June 2, 2025, HCCAD are approved to be “carved out” of the All-Patient Refined Diagnosis Related Group (APR-DRG) and can be billed on an outpatient claim for reimbursement. Specialty pharmacy billing may be utilized alternatively, if available.
For the HCCAD to be reimbursed separately from the DRG payment hospitals must bill HCCADs on a separate outpatient claim and 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, or alternate contracted reimbursement methodology. The date of administration of the drug should be used on the HCCAD outpatient claim. The above process applies to the following approved HCCAD Non-Risk Drugs:
- HEMGENIX -J1411
- ELEVIDYS -J1413
- SKYSONA -J3590
- LYFGENIA -J3394
- ZYNTEGLO -J3393
- ROCTAVIAN -J1412
- ZOLGENSMA -J3399
- CASGEVY -J3392
- KYMRIAH -Q2042
- CARVYKTI -Q2056
- ABECMA -Q2055
- BREYANZI -Q2054
- TECARTUS -Q2053
- YESCARTA -Q2041
Updates to the HCCAD list will be reviewed quarterly through the NDC-HCPC Crosswalk Vendor Drug Program.
Billing Requirements
The HCCAD claim must include all clean claim elements outlined in the Provider Manual. The HCCAD claims must also include the below:
- The NDC qualifier of N4,
- The appropriate 11‑digit National Drug Code (NDC) and corresponding HCPCS code for the drug,
- The number of units of the drug administered to the member that is covered by the claim,
- The NDC unit of measurement (F2, GR, ML, UN or ME), and
- An invoice showing the actual acquisition cost.
Please note the following:
- Condition code 20 and acquisition attachment are a requirement for reimbursement.
- On the outpatient UB04 claim form, TOB 131 should be utilized in Block 4.
- Outpatient claims billed without the required invoice will be denied as follows:
- CARC: 16- Claim/service lacks information or has submission/billing error(s):
- RARC: M23- Missing invoice
- Inpatient claims billed with HCCADs will be denied as follows:
- CARC: 16- Claim/service lacks information or has submission/billing error(s):
- RARC: M77- Missing/incomplete/invalid/inappropriate place of service
- HCCADs billed on an outpatient claim and billed/bundled with any other service will be denied:
- CARC: 16- Claim/service lacks information or has submission/billing error(s):
Prior Authorizations
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.
Next steps: Providers are encouraged to share this communication with their staff.
If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.
For access to all provider alerts,log into:
www.texaschildrenshealthplan.org/provideralerts.
