MedicaidPrior AuthMedium impact
Managed Care Entity Bulletin 125: 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 centralizing prior authorization and payment for all cell and gene therapy carve-out drugs (APAD and APEC) under the MassHealth Drug Utilization Review Program. Hospitals must now submit all prior authorization requests for these high-cost therapies directly to MassHealth DUR instead of individual MCOs or ACPPs, and MassHealth will pay these claims directly.
Action Required
Before April 1, 2025: Billing team must update prior authorization workflows to submit all APAD and APEC carve-out drug requests directly 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 on new submission procedures when MassHealth releases guidance. Claims submitted to wrong entity may be denied or delayed.