MedicaidPrior AuthMedium impact
Acute Outpatient Hospital Bulletin 42: 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
Effective April 1, 2025, MassHealth transitioned management of cell and gene therapy carve-out drugs (APAD and APEC) from MCOs/ACPPs to the MassHealth Drug Utilization Review Program. All prior authorization requests for these high-cost therapies must now be submitted directly to MassHealth DUR for review and approval before administration.
Action Required
Immediately: Billing team must update prior authorization workflows to submit all APAD and APEC carve-out drug PA requests to MassHealth DUR Program instead of MCOs/ACPPs. Review the MassHealth Acute Hospital Carve-Out Drugs List to identify affected therapies. Submit claims directly to MassHealth for payment. Continue submitting all other PA requests to applicable MCOs/ACPPs for enrolled members.