Non-Covered Codes Notification
This serves to inform you of an important update regarding the processing of certain MDHHS carve-out codes. These codes require a different claims submission process to ensure proper reimbursement.
Key Update
Previously, these carve-out codes required prior authorization (PA) through MDHHS. Moving forward, they will be considered conditional services rendered through MDHHS Fee-for-Service (FFS).
What Means for You
Claims for these carve-out codes must be sent directly to MDHHS for reimbursement. If submitted to the plan, providers will receive EXsa as the denial.
Codes Affected:
CODE | DESCRIPTION |
|---|---|
0364U | ONC HL NEO GEN SEQ ALYS ALG QUAN DMT CLNL SEQ |
77523 | PROTON BEAM DELIVERY ONE OR TWO TRMT AREAS |
77387 | GUIDANCE FOR LOCLZJ TARGET VOL FOR RADJ TX DLVR |
J0217 | INJECTION VELMANASE ALFA-TYCV 1 MG |
J0739 | INJECTION CABOTEGRAVIR 1 MG FDA-APPROVED PRSC |
J0741 | INJECTION CABOTEGRAVIR AND RILPIVIRINE 2MG/3MG |
J1322 | ELOSULFASE ALFA, INJECTION |
J1411 | INJ ETRANACOGENE DEZAPARVOVEC-DRLB PER THR DOSE |
J1413 | INJ DELANDISTROGENE MOXEPARVOVEC-ROKL PER THR D |
J1426 | INJECTION CASIMERSEN 10 MG |
J1427 | INJECTION VILTOLARSEN 10 MG |
J1428 | INJECTION ETEPLIRSEN 10 MG |
J1429 | INJECTION GOLODIRSEN 10 MG |
J1746 | INJECTION IBALIZUMAB-UIYK 10 MG |
J1961 | INJECTION LENACAPAVIR 1 MG |
J2326 | INJECTION NUSINERSEN 0.1 MG |
J3393 | INJECTION BETIBEGLOGENE AUTOTEMCEL PER TREATMENT |
J3394 | INJECTION LOVOTIBEGLOGENE AUTOTEMCEL PER TX |
J3398 | INJECTION VORETIGENE NEPARVOVEC-RZYL 1 B VEC G |
J3399 | INJ AVSX-101-XIOI P-TX TO 5X10^15 VCTR GNOMS |
J3590 | UNCLASSIFIED BIOLOGICS |
L5645 | ADD LOW EXT BELOW KNEE FLEX INNER EXT FRAME |
Q2041 | KTE-C19 TO 200 M A ANTI-CD19 CAR POS T CE P TD |
Q2042 | TISAGENLECLEUCEL TO 600 M CAR-POS VI T CE PER TD |
Q2053 | BREXUCABTAGENE AUTOLCL AU ANTI-CD19 CAR P V T C |
Q2054 | LM >=110 MIL AUTOL ANTI-CD19 CAR-POS VIABL TC |
Q2055 | IDECABTAGENE VICLEUCEL AUTO BCMA DIR CAR-POS TC |
Q2056 | CILTA CEL TO 100 M AUTO BCMA DIR CAR-POS TC DOSE |
Next Steps
Submit claims for these codes directly to MDHHS for reimbursement
We appreciate your cooperation in implementing these updates to maintain compliance with MDHHS guidelines. Thank you for your attention to this update and for your continued partnership.