GHP Family high-cost drug billing policy

GHP Family has established billing requirements for high-cost drugs to ensure compliance with federal and state regulations, DHS policies, and the HealthChoices Agreement.

Definition of high-cost drugs

A high-cost drug is defined as a drug listed on the official FDA-approved cellular and gene therapy products list.

General billing requirements

• Providers designated as 340B-covered must dispense/administer non-340B purchased products for Medicaid members.
• Claims must comply with HealthChoices Appendix 18B requirements.
• Providers are responsible for accurate reporting and adherence to 340B carve-out status. This includes ensuring that all records related to patient eligibility and drug dispensing are accurate and up-to-date.

Billing specifications

• Use Revenue Code 636 with the applicable HCPCS code (e.g., J-codes).
• Include National Drug Code (NDC) and NDC units on all claims.
• Submit claims as 837 Institutional type.
• Each high-cost drug must be billed as a single line item, even if bundled into another payment rate.

Inpatient facility billing

• High-cost drugs administered in inpatient settings are generally bundled into APR DRG payments.
• If separate reimbursement is allowed:
• Bill the drug on a separate service line.
• Do not include other services (e.g., administration) on the same claim.
• Administration services should be billed separately.

NDC reporting requirements

• Drug products must be marketed by a labeler participating in the Federal Medicaid Drug Rebate Program.

Claim form instructions

• CMS-1500: Enter NDC in shaded sections of item 24A–24G with qualifier and 11-digit NDC (no hyphens).
• UB-04: Enter NDC in Revenue Description Field (Form Locator 43) with qualifier and 11-character NDC.
• EDI: Report NDC in Loop 2410 LIN3.

Cell and gene therapy for sickle cell disease

GHP Family will reimburse for Lyfgenia and Casgevy under the CMS Access Model for members with Sickle Cell Disease, contingent upon:

• Provider participation in the CIBMTR registry and CMS-specified study.
• Administration in an inpatient setting.