Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective for dates of service on or after June 1, 2018, nusinersen (procedure code J2326) is a benefit for durable medical equipment (DME) pharmacy providers when provided in the office or outpatient hospital setting.
Procedure code J2326 requires prior authorization. If nusinersen is dispensed by a DME pharmacy via white bagging, the rendering provider must provide the prior authorization number to the dispensing DME pharmacy. The dispensing DME pharmacy may not request prior authorization.
The dispensing DME pharmacy will be responsible for obtaining the prior authorization number from the rendering provider.
The rendering provider (physician or hospital) may coordinate with the DME pharmacy provider for the initial or recertification prior authorization request for nusinersen. DME pharmacy providers may assist in providing necessary information such as their National Provider Identifier (NPI), fax number, and business address to the rendering provider. However, the Special Medical Prior Authorization (SMPA) Request Form must be signed, dated, and submitted by the Medicaid-enrolled rendering provider, not the DME pharmacy provider.
When submitting a claim for procedure code J2326, the dispensing DME pharmacy must include the prior authorization number on the claim form. The DME pharmacy provider submitting the claim must be identified in the “Service provider or facility information” field of the prior authorization request. The dispensing DME pharmacy will not be reimbursed unless the prior authorization request has been approved.
Note: DME pharmacy providers may refer to the current Texas Medicaid Provider Procedures Manual, Appendix B: Vendor Drug Program, subsection B.3.5.1, “Pharmacy Delivery Method for Clinician-Administered Drugs,” for more information about white bag delivery.
For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.