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Reimbursement Rate Updates for Procedure Code J1429 Effective July 1, 2020

Last updated on 7/31/2020

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.

Effective July 21, 2020, for dates of service on or after July 1, 2020, the reimbursement rate for procedure code J1429 (Vyondys 53) will be updated.

Drugs

Type of Service: Medical Services Procedure Code Age Range Non-Facility (N)/ Facility (F) Current Medicaid Fee Percent Reduction Current Adjusted Medicaid Fee Medicaid Fee Effective 7/1/2020 Percent Reduction Adjusted Medicaid Fee Effective 7/1/2020
1 J1429 0-999 N/F Not a Benefit 0.00% Not a Benefit $1,718.40 0.00% $1,718.40

Affected claims with dates of service from July 1, 2020, through July 21, 2020, if any are identified, will be reprocessed. Providers are not required to appeal the claims unless they are denied for additional reasons after the claims reprocessing is completed.

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