P-15.5. Clinician-administered Drug Claim Submission

Beginning September 1, 2015, all covered entities must use the modifier "U8" when submitting medical claims for 340B clinician-administered drugs. Medical claims for clinician-administered drugs (CAD) (also known as physician-administered drugs) include Healthcare Common Procedure Coding System (HCPCS) codes listed on the Formulary search (txvendordrug.com/formulary/formulary-search). The CAD search identifies the relationship between a rebate-eligible NDC and HCPCS code.

Providers can access the NDC Requirements for the Submission of CAD Claims instruction within the TMHP Learning Management System (LMS) for detailed information about CAD claim submission. Refer to the TMHP Resources section for details about the TMHP LMS and how to register.

The covered entity must correctly submit claims filled with 340B drugs for 340B clients to ensure HHSC does not collect rebates for these drugs. Non-compliance with this requirement may jeopardize a covered entity's 340B status with HRSA. This modifier requirement for 340B clinician-administered drugs applies to Medicaid fee-for-service claims submitted to TMHP and Medicaid managed care claims submitted to the client's MCO.

Providers who believe NDCs are missing for a specific HCPCS procedure code can contact HHSC to request a review. The email should include the procedure codes and corresponding NDCs. Contact the Clinician-administered Drug Administration to request a HCPCS review.

For more information related to the submission of medical claims, call the TMHP Contact Center.