North Carolina Medicaid: Billing guidance for cell and gene therapy treatments
AI Summary
North Carolina Medicaid now allows providers to participate in the Cell and Gene Therapy (CGT) Access Model, providing eligible Medicaid enrollees access to cell and gene therapy treatments at reduced costs. Prior authorization is required for all CGT treatments through UnitedHealthcare Community Plan, with specific billing procedures for different drug therapies.
Action Required
Immediately: Billing team must obtain prior authorization before providing any CGT treatments to UnitedHealthcare Community Plan members. For drugs J1411 (Hemgenix), J3398 (Luxturna), J1413 (Elevidys), J1412 (Roctavian), and J3393 (Zynteglo), submit prior auth requests through UnitedHealthcare Provider Portal. For Casgevy, LenmeldyTM, Lyfgenia, Skysona, and Zynteglo, contact Optum Transplant Services at 888-802-1802. Do not bill members for services provided without prior authorization as claims will be denied.
Affected Billing Codes
Plan Types
Medicaid
States
NC
Specialties
oncology, hematology, ophthalmology, neurology