MedicaidPrior AuthMedium impact
Acute Inpatient Hospital Bulletin 203: Correction of Cell and Gene Therapy Adjudicated Payment Amount per Discharge and Adjudicated Payment per Episode of Care Carve-Out
MassHealth·MA · Oncology, Hematology·Claims & Billing
Effective date
Apr 1, 2025
We identified it
Jun 18, 2026
Summary
MassHealth has centralized all prior authorization and payment for cell and gene therapy carve-out drugs (APAD and APEC) under the MassHealth Drug Utilization Review Program. Hospitals must now submit PA requests to MassHealth DUR instead of individual MCOs/ACPPs, and MassHealth will pay these claims directly.
Action Required
Immediately: Billing team must update prior authorization workflow for cell and gene therapy carve-out drugs. Submit all PA requests for APAD and APEC carve-out drugs to MassHealth DUR Program instead of MCOs/ACPPs. Submit claims directly to MassHealth for payment. Refer to MassHealth Acute Hospital Carve-Out Drugs List for specific covered drugs and submission procedures.