Skip to main content

Submitting Claims for HCCAD Skysona With U3 Modifier (Procedure Code J3590)

Last updated on

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Skysona (procedure code J3590) is a high-cost clinician-administered drug (HCCAD) that is currently a benefit of Texas Medicaid. For dates of service on or after June 1, 2025, hospitals with prior authorization can submit a separate outpatient claim for Skysona when the drug is provided in an inpatient setting. Providers should not submit a claim for Skysona on the related inpatient services claim.

Providers must submit the following elements on a fee-for-service (FFS) outpatient claim so that the Texas Medicaid & Healthcare Partnership (TMHP) can easily identify Skysona claims and reimburse them separately from the inpatient claims:

  • Procedure code J3590
  • Modifier U3
  • The appropriate national drug code (NDC)

The modification to the TMHP FFS claims processing system to reimburse Skysona at the fee schedule rate will not be complete until December 19, 2025. TMHP will initially process the outpatient claims for Skysona that are submitted by hospital providers at the current hospital outpatient reimbursement rate. TMHP will reprocess claims that are submitted before December 19, 2025, after the claims processing system modifications are complete.

Refer to the Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 8.2, “HCCADs Claims Processing Requirements,” for additional information about claims processing requirements for Skysona and other HCCADs.

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