Date: July 10, 2025
Attention: Hospital Providers
Effective date: June 1, 2025
Call to action: Skysona (procedure code J3590) is a high-cost clinician-administered drug (HCCAD) that is currently a benefit of Texas Medicaid. For dates of service on or after June 1, 2025, hospitals with prior authorization can submit a separate outpatient claim for Skysona when the drug is provided in an inpatient setting. Providers should not submit a claim for Skysona on the related inpatient services claim.
How this impacts providers: Providers must submit the following elements on a fee-for-service (FFS) outpatient claim so that the Texas Medicaid & Healthcare Partnership (TMHP) can easily identify Skysona claims and reimburse them separately from the inpatient claims:
The modification to the TMHP FFS claims processing system to reimburse Skysona at the fee schedule rate will not be complete until December 19, 2025. TMHP will initially process the outpatient claims for Skysona that are submitted by hospital providers at the current hospital outpatient reimbursement rate. TMHP will reprocess claims that are submitted before December 19, 2025, after the claims processing system modifications are complete.
Next step for Providers: Providers should share this communication with their billing staff.
If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.
For access to all provider alerts: www.texaschildrenshealthplan.org/provideralerts.