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

Inpatient high-cost clinician-administered drugs (HCCADs) are drugs or biologics that the Texas Health and Human Services Commission (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.

The section below contains the list of HCCADs, and procedure codes approved by HHSC:

Reimbursement Policy Update

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.

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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