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Additional Diagnosis Code Added for Eculizumab

Last updated on 4/29/2020

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.

Beginning April 30, 2020, for dates of service on or after July 1, 2019, diagnosis code G360 will be added as a payable diagnosis for Eculizumab (procedure code J1300).

Affected claims submitted for dates of service from July 1, 2019 through April 30, 2020 will be reprocessed, and providers may receive additional reimbursement, which will be reflected on future Remittance and Status Reports.

For a list of additional payable diagnosis codes and restrictions, providers can refer to the Texas Medicaid Provider Procedures Manual, Clinician-Administered Drugs Handbook, subsection 6.1.4, “Nonspecific, Unlisted or Miscellaneous Procedure Codes.”

For more information, call the TMHP Contact Center at 800-925-9126.