MedicaidPrior AuthHigh impact
Updated Preauthorization and Billing Instructions for Zolgensma®
Maryland Medicaid·MD · Neurology, Pediatrics, Pharmacy·Provider Transmittal
Effective date
Jan 1, 2021
We identified it
Jun 20, 2026
Summary
Effective January 1, 2021, Maryland Medicaid updated billing and preauthorization procedures for Zolgensma®. HealthChoice MCOs now handle preauthorization and payment for managed care participants, while Fee-for-Service claims use J3399 HCPCS code with an 11-digit NDC number. Physicians must submit CMS-1500 claims via fax only (electronic claims rejected); pharmacies must obtain prior authorization before dispensing. This policy supersedes four prior transmittals.
Action Required
By December 31, 2020: (1) Billing team must update all billing system configurations to require prior authorization for Zolgensma® through either the Professional Services Program OR Pharmacy Program—NOT both—to avoid claim denials. (2) Update claim submission procedures: for physician-administered Zolgensma®, configure billing software to use HCPCS code J3399 with valid 11-digit NDC number on CMS-1500 claims and submit via fax to 410-767-6034 only (disable electronic submission for this drug). (3) For pharmacy-dispensed Zolgensma®, ensure prescribers complete preauthorization through the Pharmacy Program before dispensing. (4) Update provider templates and training materials to clarify that only ONE preauthorization per participant is permitted across all programs. (5) Create internal workflow to route HealthChoice participant preauthorization requests to their respective MCO instead of MDH. (6) Verify that J3399 with the supplied NDC is rebatable through Maryland Medical Program's Web Services NDC Unit of Measure Listing before billing. Failure to obtain preauthorization or submitting claims through wrong program will result in claim denials.