MedicaidPrior AuthMedium impact
Acute Outpatient Hospital Bulletin 41: 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 is transitioning prior authorization review for all cell and gene therapy carve-out drugs from MCOs/ACPPs to the centralized MassHealth Drug Utilization Review Program. All PA requests for these high-cost therapies must now be submitted to DUR instead of individual health plans.
Action Required
By April 1, 2025: Billing team must update prior authorization workflows to submit all APAD and APEC carve-out drug requests to MassHealth DUR Program instead of MCOs/ACPPs. Review the MassHealth Acute Hospital Carve-Out Drugs List to identify affected therapies. Update staff training on new submission procedures when MassHealth releases detailed guidance. Continue submitting all other PA requests to applicable MCO/ACPP.