CurrentHumanaPolicy CP2025010

Cell and Gene Therapy (CGT) Access Model

Defines Humana's billing requirements and reimbursement approach for model drugs and services rendered under the CMS Cell and Gene Therapy (CGT) Access Model for Kentucky Medicaid providers.

Policy Summary

PayerHumana

PolicyCell and Gene Therapy (CGT) Access Model

Policy CodePolicy CP2025010

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionReport model drugs on paper UB-04 claim forms and use TOB 13x to enable separate reimbursement from the inpatient DRG.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

UB-04 requiredClaim form requirement

TOB 13xType of bill for separate payment

Disallowed340B discounts

DeniedModifiers TB/UD

CGT Model Drug Billing and Payment Rules

CGT model drug billing and payment rules

Payment and billing rules for model drugs under the CGT Access Model in Kentucky Medicaid:

Providers must report CGT services consistent with applicable guidance from the Kentucky Department for Medicaid Services.

Model drugs rendered as part of the CGT Access Model must be reported on paper UB-04 claim forms.

Claim form requirement: UB-04 (paper) required.

To facilitate separate reimbursement from the inpatient DRG, the facility should report the model drug on a UB-04 claim form with TOB 13x.

Use TOB 13x for separate payment from DRG.

Providers may not claim discounts under the 340B Drug Pricing Program for model drugs rendered as part of the CGT Access Model; Humana denies model drugs reported with modifier TB or modifier UD.

Modifiers TB and UD are not accepted for model drugs under the CGT Access Model.

Policy Summary

PayerHumana

PolicyCell and Gene Therapy (CGT) Access Model

Policy CodePolicy CP2025010

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionReport model drugs on paper UB-04 claim forms and use TOB 13x to enable separate reimbursement from the inpatient DRG.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Claim Forms, Type of Bill, and 340B Modifiers

340B-related modifiersModifierNot Covered

TB	Modifier TB — Drug or biological acquired with 340B Drug Pricing Program discount
UD	Modifier UD — Physician administered drug purchased through the 340B Drug Pricing Program

Claim form requirement

Required claim formModel drugs rendered as part of the CGT Access Model must be reported on paper UB-04 claim forms.

Type of Bill (TOB)To facilitate separate reimbursement from the inpatient DRG, the facility should report the model drug on a UB-04 with TOB 13x.

Separate reimbursementHumana reimburses model drugs rendered as part of the CGT Access Model separately from the inpatient hospital DRG payment.

340B discounts disallowedProviders may not claim discounts under the 340B Drug Pricing Program when purchasing model drugs rendered as part of the CGT Access Model.

Claims Submission and Reporting Requirements

Billing Rule

Claims submission and reporting

Providers must report CGT services consistent with applicable Kentucky Department for Medicaid Services guidance; model drugs rendered as part of the CGT Access Model must be reported on paper UB-04 claim forms. To ensure separate reimbursement from the inpatient DRG, the facility should report the model drug on a UB-04 claim form with type of bill 13x.

Do not claim 340B Drug Pricing Program discounts for model drugs rendered under the CGT Access Model — Humana denies model drugs reported with modifier TB or UD.
Use a paper UB-04 and TOB 13x to facilitate separate payment from the inpatient DRG.

Modifier Definitions

Modifier TB

Modifier TB definitionModifier TB — Drug or biological acquired with 340B Drug Pricing Program discount.

Payment effectHumana denies model drugs reported with modifier TB when rendered as part of the CGT Access Model.

ContextTB is used to indicate drugs acquired with a 340B discount; 340B discounts are not allowed for CGT model drugs under this policy.

Modifier UD

Modifier UD definitionModifier UD — Physician administered drug purchased through the 340B Drug Pricing Program.

Payment effectHumana denies model drugs reported with modifier UD when rendered as part of the CGT Access Model.

ContextUD indicates a physician‑administered drug purchased via 340B; 340B discounts are disallowed for CGT model drugs under this policy.