MedicaidPrior AuthMedium impact
North Carolina Medicaid: Billing guidance for cell and gene therapy treatments
UnitedHealthcare·NC · Oncology, Hematology·State news
Effective date
Feb 11, 2026
We identified it
Jun 13, 2026
Summary
North Carolina Medicaid now participates in the Cell and Gene Therapy Access Model, requiring prior authorization for specific CGT treatments through UnitedHealthcare Community Plan. Providers must obtain prior auth before billing for listed CGT drugs or face claim denials.
Action Required
Immediately: Billing team must obtain prior authorization before providing any CGT treatments listed (Hemgenix, Luxturna, Elevidys, Roctavian, Zynteglo) to UnitedHealthcare Community Plan members in North Carolina. Use UnitedHealthcare Provider Portal for J1411, J3398, J1413, J1412, J3393, or call Optum Transplant Services at 888-802-1802 for Casgevy, Lenmeldys, Lyfgenia, Skysona, Zynteglo. Claims will be denied without prior authorization.