MedicaidPrior AuthHigh impact
Acute Inpatient Hospital Bulletin 201: 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
Starting April 1, 2025, MassHealth is transferring prior authorization review for all cell and gene therapy carve-out drugs from MCOs/ACPPs to the centralized MassHealth Drug Utilization Review Program. All prior authorization requests for these high-cost therapies must now be submitted to DUR instead of individual managed care plans.
Action Required
By April 1, 2025: Billing team must update prior authorization submission procedures for all APAD and APEC carve-out drugs (cell and gene therapies) to route PA requests to MassHealth Drug Utilization Review Program instead of MCOs/ACPPs. Review the MassHealth Acute Hospital Carve-Out Drugs List to identify affected therapies. Update staff training and workflow documentation to reflect new centralized PA process. Continue submitting all other PA requests to applicable MCO/ACPP for MassHealth members.