5. Clinician-administered Drug Claim Submission
Beginning September 1, 2015, all eligible organizations and covered entities that are enrolled in the federal 340B Drug Pricing Program to purchase 340B discounted drugs must use modifier “U8” when submitting claims for 340B clinician-administered 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 for Medicaid fee-for-service claims submitted to TMHP and Medicaid managed care claims submitted to the patient’s managed care organization.
It is the responsibility of the covered entity to correctly submit claims filled with 340B stock for 340B-eligible patients to ensure rebates are not collected for these drugs.
For all clinician-administered drug claims, all Texas Medicaid providers must submit a rebate-eligible National Drug Code (NDC) and modifier “U8” for professional or outpatient claims, including Medicare crossover claims submitted to TMHP, with a clinician-administered drug-related Healthcare Common Procedure Coding System (HCPCS). Texas Medicaid defines clinician-administered drugs as physician-administered drugs for procedure codes listed on the Texas NDC-to-HCPCS Crosswalk.
The NDC is an 11-digit number on the package or container from which the medication is administered. Providers must enter modifier “N4” in front of the NDC code on all claim forms. The "NDC Quantity" and the "NDC Unit of Measure" must be entered on all professional or outpatient claims that are submitted to TMHP. TMHP edits medical claims against the crosswalk, which identifies relationships between rebate-eligible NDC and HCPCS codes. All claims with a HCPCS code listed on the crosswalk require a corresponding NDC.
Refer to the Clinician-administered Drug Search for a list of CAD drugs.
If a provider believes that NDCs are missing for a specific HCPCS procedure code, the provider can submit an email to email@example.com requesting an update to the crosswalk. The email should include the procedure code(s) and corresponding NDCs that are believed to be missing.
For more information related to submission of medical claims, call the TMHP Contact Center at 1-800-925-9126.