Medicaid provider update: High-cost Medicaid drug billing

IMMEDIATELY: Billing team must implement the following changes to comply with UPMC Medicaid drug billing requirements: (1) Update billing software to enforce 837 Professional or 837 Institutional claim format submission for all high-cost Medicaid drugs. (2) Modify billing validation rules to require accurate National Drug Codes (NDCs) and NDC units dispensed on all drug claims, with corresponding J-code on the same claim line. (3) Configure system to reject or flag claims that combine drug billing with other services on a single line; drug administration must be billed on a separate claim. (4) For 340B provider accounts: Update billing logic to automatically append UD modifier for 340B-purchased drugs and prohibit UD modifier for non-340B drugs. (5) Create a hard stop in the billing system to prevent 340B drug dispensing/administration for any drugs listed in Appendix 18B of the MCO Agreement, particularly Lyfgenia and Casgevy (Cell and Gene Therapy exclusions). (6) For CGT therapies (Lyfgenia, Casgevy): Configure system to require non-340B inventory only for Medicaid patients and verify provider registration with CIBMTR and CMS study participation before claim submission. (7) Train billing staff on these requirements immediately, with emphasis on the 340B modifier rules and CGT exclusions. Failure to comply will result in claim denials and potential compliance violations with CMS Medicaid Drug Rebate Program. Reference Appendix 18B of MCO Agreement for complete exclusion list and contact UPMC provider relations for any questions on applicability to your specific drug inventory.