CurrentDell Children's Health PlanPolicy N/A

Implementation plan for High-Cost Clinician Administered Drugs (HCCAD): Separate reimbursement and claims processing requirements

Customize your policy alerts

Sign up for all dellchildrenshealthplan policy alerts

Know when dellchildrenshealthplan releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs implementation, billing, reimbursement, and claims-processing requirements for HHSC-approved high-cost clinician-administered drugs administered in inpatient settings but billed separately on outpatient claims for Medicaid fee-for-service and managed care.

Policy Summary

PayerDell Children's Health Plan

PolicySeparate reimbursement and claims processing for HCCADs

Policy CodePolicy N/A

Change TypeNew implementation

Effective DateJun 2, 2025

Next Review DateN/A

Key ActionSubmit a separate outpatient claim for each HCCAD, separate from claims for other hospital services provided during the same visit.

SourceLink

POLICY UPDATE CHANGES

Separate outpatient reimbursement for approved HCCADs.

New HCCAD claim data and invoicing requirements.

Prior authorization is mandatory for HCCADs.

14HCCAD products listed

N4Required NDC qualifier

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentDell Children's Health PlanPolicy N/A

Implementation plan for High-Cost Clinician Administered Drugs (HCCAD): Separate reimbursement and claims processing requirements

Customize your policy alerts

Sign up for all dellchildrenshealthplan policy alerts

Know when dellchildrenshealthplan releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerDell Children's Health Plan

PolicySeparate reimbursement and claims processing for HCCADs

Policy CodePolicy N/A

Change TypeNew implementation

Effective DateJun 2, 2025

Next Review DateN/A

Key ActionSubmit a separate outpatient claim for each HCCAD, separate from claims for other hospital services provided during the same visit.

SourceLink

POLICY UPDATE CHANGES

Separate outpatient reimbursement for approved HCCADs.

New HCCAD claim data and invoicing requirements.

Prior authorization is mandatory for HCCADs.

14HCCAD products listed

N4Required NDC qualifier

Allowed NDC unit values

20Financial Arrangement Code

Lesser of FFS or costReimbursement limit

Separate HCCAD Reimbursement Requirements

Requirements for separate HCCAD reimbursement

Separate HCCAD reimbursement is available only when ALL of the following requirements are met:

ALL of the following

The drug or biologic is an HHSC-approved high-cost clinician-administered drug (HCCAD) eligible to be carved out of the APR-DRG and billed on an outpatient claim.
The hospital submits a separate outpatient claim for the HCCAD, distinct from facility and institutional claims for all other hospital services provided during the same visit.
The claim uses the date of drug administration as the date of service.
The claim includes the required N4 NDC qualifier, the appropriate 11-digit National Drug Code (NDC), the corresponding HCPCS code, the number of covered units administered, and an allowed NDC unit of measurement: F2, GR, ML, UN, or ME.
The hospital submits an invoice documenting the drug's actual acquisition cost.
The mandatory HHSC-approved prior authorization criteria for HCCADs are satisfied, as specified in the Outpatient Drugs Handbook of the Texas Medicaid Provider Procedure Manual.

HCCAD Coding and Reimbursement Parameters

NDC qualifierNDC

N4	NDC qualifier required on the HCCAD outpatient claim

Drug identification codesmixed

11-digit NDC	Appropriate National Drug Code for the administered drug
HCPCS	Corresponding Healthcare Common Procedure Coding System code for the drug

HCCAD product listmixedCovered

HEMGENIX	Listed HCCAD product
ELEVIDYS	Listed HCCAD product
SKYSONA	Listed HCCAD product
LYFGENIA	Listed HCCAD product
ZYNTEGLO	Listed HCCAD product
ROCTAVIAN	Listed HCCAD product
ZOLGENSMA	Listed HCCAD product
CASGEVY	Listed HCCAD product
KYMRIAH	Listed HCCAD product
CARVYKTI	Listed HCCAD product

1–10 of 14

1/2

NDC Unit of Measurement

F2Permitted NDC unit of measurement

GRPermitted NDC unit of measurement

MLPermitted NDC unit of measurement

UNPermitted NDC unit of measurement

MEPermitted NDC unit of measurement

Financial Arrangement Code

Provider Billing and Claims Actions

Prior Authorization

Prior authorization is mandatory

Apply the mandatory HHSC-approved prior authorization criteria for HCCADs found in the Outpatient Drugs Handbook of the Texas Medicaid Provider Procedure Manual before submitting the claim.

Billing Rule

Submit a separate HCCAD claim

Submit a separate outpatient claim for the HCCAD and keep it separate from facility and institutional claims for all other hospital services provided during the same visit. HCCAD payment must not be bundled with any other service.

Key Terms

High-Cost Clinician Administered Drugs (HCCADs)

DefinitionDrugs or biologics that HHSC has approved to be carved out of the All-Patient Refined Diagnosis Related Group (APR-DRG)

Payment treatmentHCCADs can be billed on an outpatient claim rather than included in the APR-DRG payment

ScopeApplies to high-cost clinician-administered drugs and biologics approved by HHSC

Diagnosis Related Group (DRG) Payment

DefinitionA hospital payment reflecting all average hospital costs associated with the patient’s primary diagnosis and complications

Separate drug reimbursementDRG payments generally exclude separate reimbursement for high-cost drugs or biologics

Policy Summary

PayerDell Children's Health Plan

PolicySeparate reimbursement and claims processing for HCCADs

Policy CodePolicy N/A

Change TypeNew implementation

Effective DateJun 2, 2025

Next Review DateN/A

Key ActionSubmit a separate outpatient claim for each HCCAD, separate from claims for other hospital services provided during the same visit.

SourceLink

On This Page

Required onMedical encounters for HCCAD non-risk reimbursement

Related payment arrangementManaged care organizations are reimbursed non-risk for the HCCAD

Reimbursement Ceiling

Maximum reimbursementThe lesser of the fee-for-service rate or the drug’s actual acquisition cost from the invoice

Acquisition-cost documentationThe hospital must submit an invoice documenting the drug’s actual acquisition cost

Non-risk payment limitLimited to the actual amount paid to providers for the drug’s ingredient cost, up to the FFS reimbursement amount

Documentation Required

Include required drug identifiers and units

Include the required drug identifiers and administration details on the HCCAD claim.

NDC qualifier: N4
Appropriate 11-digit National Drug Code (NDC) and corresponding HCPCS code
Number of units of the drug administered that is covered by the claim
NDC unit of measurement: F2, GR, ML, UN, or ME

Billing Rule

Use administration date

Use the date of administration of the drug as the date of service on the HCCAD outpatient claim.

Documentation Required

Submit acquisition-cost invoice

Submit an invoice documenting the drug’s actual acquisition cost. Reimbursement is based on the fee-for-service rate or the actual acquisition cost from the invoice, whichever is less.

HCCAD relationshipHHSC-approved HCCADs are carved out of the APR-DRG and billed on an outpatient claim

Non-risk Reimbursement

DefinitionA payment arrangement under which managed care organizations are reimbursed for HCCADs without risk

Financial Arrangement CodeMedical encounters must contain the value 20

Reimbursement limitationNon-risk payment is limited to the actual amounts paid to providers for the drug’s ingredient cost, up to the FFS reimbursement amount