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GHP Family high-cost drug billing policy
Effective date
Not stated in the notice
Identified
Jul 29, 2026
Summary
GHP Family has established new billing requirements for high-cost drugs (FDA-approved cellular and gene therapy products), including mandatory use of Revenue Code 636, HCPCS codes, NDC reporting on all claims, and specific form submission rules (837 Institutional, CMS-1500, or UB-04). For sickle cell disease therapies (Lyfgenia and Casgevy), reimbursement requires inpatient administration and CIBMTR registry participation.
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What to do
Action · 11 steps
01IMMEDIATE: Billing team must implement the following changes to comply with GHP Family high-cost drug billing policy.
02Update billing system to require Revenue Code 636 for all high-cost drug claims.
03Ensure all high-cost drug claims include 11-digit NDC (no hyphens) in the appropriate form fields—CMS-1500 Item 24A-24G shaded sections, UB-04 Form Locator 43 Revenue Description Field, or EDI Loop 2410 LIN3.
04Configure system to submit all high-cost drug claims as 837 Institutional type only.
05Verify each high-cost drug is billed as a single separate line item, never bundled with other services.
06For inpatient high-cost drugs: bill on separate service line with NDC and units; do NOT include administration services on same claim—submit administration separately.
07Establish verification process to confirm all drug products are marketed by Federal Medicaid Drug Rebate Program participants.
08For Lyfgenia and Casgevy (sickle cell): verify inpatient administration setting and CIBMTR registry enrollment before processing claims.
09Update encounter forms and provider documentation templates to capture required NDC and eligibility information.
10Train all billing staff on new Revenue Code 636 and NDC reporting requirements.
11Non-compliance will result in claim denials and potential audit findings.
Original notice
GHP Family high-cost drug billing policy
geisinger.org · Always check the source before changing claims.