Reimbursement Update for High-Cost Clinician-Administered Drugs (HCCADs)

Effective June 2, 2025, there will be a change in reimbursement for the following High-Cost
Clinician-Administered Drugs (HCCAD):

Reimbursement Policy Update

Separate Reimbursement of Certain Inpatient HCCADs

Inpatient high-cost clinician-administered drugs (HCCADs) are drugs or biologics that HHSC has approved to be “carved out” of the All-Patient Refined Diagnosis Related Group (APR-DRG) and can be billed on an outpatient claim.

This section allows for the use of specialty pharmacy billing for the HCCAD if it is available for the drug or bill for the HCCAD on a separate outpatient claim.

If specialty pharmacy will be submitting a claim for the HCCAD, the claim must be submitted in an approved electronic format or on the CMS-1500 paper claim form.

If the hospital will be submitting the claim, follow process detailed below.

Hospitals must submit claims for these HCCADs separately as outpatient claims on a UB04. These drugs will no longer be reimbursed under the All-Patient Refined Diagnosis Related Group (APR-DRG) payment system. Instead, reimbursement will be made as direct payments based on the lesser of:

1. The Texas Medicaid Fee-For-Service (FFS) rate, or
2. The actual acquisition cost, as documented by an invoice.

Billing Requirements

To ensure proper reimbursement, hospitals must:

• Submit a separate outpatient claim on a UB04 for the HCCAD, separate from any institutional/facility claim for other hospital services provided on the same date.
• Include the following details in the claim:
  • NDC Qualifier: N4
  • 11-digit National Drug Code (NDC) and corresponding HCPCS code
  • Number of units administered
• NDC unit of measurement (F2, GR, ML, UN, or ME)
• Use the date of drug administration as the date of service on the claim.
• Submit an invoice reflecting the actual acquisition cost of the drug.

Note: Drugs administered during an inpatient setting do not qualify for 340B.

Please refer to the most recent version of the TMPPM Outpatient Drug Services Handbook for the most updated list of HCCADS and any updated billing information.

Action:

Providers are encouraged to share this information with their staff. If you have any questions about this notice, please email Provider Relations at ProviderRelations@cfhp.com or call 210-358-6030. You can also contact your Provider Relations Representative directly.

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