North Carolina Medicaid: Billing guidance for cell and gene therapy treatments
AI Summary
North Carolina Medicaid providers can now participate in the Cell and Gene Therapy (CGT) Access Model effective immediately. Prior authorization is required for all CGT treatments before providing services to UnitedHealthcare Community Plan members, with specific HCPCS codes requiring approval through either the Provider Portal or Optum Transplant Services.
Action Required
Immediately: Billing team must obtain prior authorization before providing any cell and gene therapy treatments to UnitedHealthcare Community Plan members in North Carolina. For drugs J1411 (Hemgenix), J3398 (Luxturna), J1413 (Elevidys), J1412 (Roctavian), and J3393 (Zynteglo), submit prior auth requests through UnitedHealthcare Provider Portal. For Casgevy, Lenmeldy, Lyfgenia, Skysona, and Zynteglo, contact Optum Transplant Services at 888-802-1802. Claims will be denied and members cannot be billed for services provided without prior authorization.
Affected Billing Codes
Plan Types
Medicaid
States
NC
Specialties
oncology, hematology, neurology, ophthalmology