MedicaidBilling CodesMedium impact
Medicaid Alert MA-2025-04
New Jersey Medicaid·NJ · Hematology, Oncology, Transplant Surgery +2 more·Coding
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid is implementing the CMS Cell and Gene Therapy (CGT) Access Model for Sickle Cell Disease gene therapies (Casgevy and Lyfgenia). Effective January 1, 2026, providers must submit drug costs on separate professional CMS 1500 claims with actual acquisition costs and purchase invoices, exclude drugs from facility/DRG bundling, and comply with registry and study participation requirements.
Action Required
By December 31, 2025: Billing team must implement the following changes for NJ FamilyCare claims:
1. Update billing system to prevent bundling HCPCS codes J3392 (Casgevy) and J3394 (Lyfgenia) into facility claims, DRGs, or APCs. These drugs must be billed separately on CMS 1500 professional claims only.
2. Configure system to require attachment of drug purchase invoices to all CGT claims, with the "Charge" field matching actual drug acquisition cost from invoice.
3. Establish claim submission workflow to include: HCPCS code, NDC (National Drug Code), UOM (Unit of Measure), and number of units administered. Reference www.njmmis.com for correct UOMs.
4. Block duplicate payments by implementing logic to flag if drug is billed via both POS and professional claim—reject duplicates.
5. Add compliance check: Verify provider is CIBMTR registry member and participating in CMS SCD gene therapy study. Contact Gainwell Provider Services (1-800-776-6334) to confirm eligibility.
6. Prohibit 340B pricing: Update purchasing and billing rules to ensure J3392 and J3394 are not sourced from 340B inventory.
7. Train billing staff on new submission requirements and reference NJ FamilyCare Managed Care Contract and Medicaid Newsletter Volume 19, Number 18 (available on www.njmmis.com).
Consequences: Claims submitted without separate professional claims, proper documentation, or from non-compliant providers will be denied. Bundled claims will be rejected.