MedicaidPrior AuthMedium impact
[Ohio] Ohio Medicaid Coverage of Itvisma
CareSource·OH · Pediatrics, Neurology, Genetics·Provider Bulletin
Effective date
Dec 29, 2025
We identified it
May 9, 2026
Summary
Ohio Medicaid now covers Itvisma (onasemnogene abeparvovec-brve) for eligible patients under both Fee-for-Service and Managed Care plans, effective December 29, 2025. All claims for this drug require prior authorization through FFS, and hospitals must split billing: submit all services except the medication to the MCO, then submit a separate FFS outpatient claim for drug acquisition charges only using revenue code 631 with HCPCS codes J3490 or J3590.
Action Required
By December 29, 2025: Billing team must implement split-billing process for Itvisma claims. (1) Update billing software to recognize Itvisma prior authorization requirement and route all claims through FFS for prior auth approval before submission. (2) Configure system to submit non-medication hospital services (inpatient or outpatient) to patient's MCO first. (3) Create separate FFS outpatient claim submission process for medication only, using revenue code 631 with J3490 or J3590 and medication-specific NDC. (4) Ensure providers document medical necessity for prior authorization. (5) Train billing staff and providers on dual-submission workflow. Contact CareSource Provider Services (1-800-488-0134, Mon-Fri 7am-8pm ET) with questions. Failure to obtain prior authorization or improper billing split will result in claim denials.