NJ Medicaid: Sickle cell Disease Generally Therapy- billing and coding

Are you a provider in NJ that accepts NJ Managed Medicaid plans in your practice? Then this blog post is for you!

When: this applies for any services done on/and after Jan 1, 2026.

Who is eligible for reimbursement? Providers that are a member of the Center of International Blood and Marrow Transplant Research patient registry AND the provider must participate in the CMS study related to SCD gene therapies.

3. Which Plans- NJ Managed Medicaid Plans, ex. UHC Community Plan

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Billing:

1. Professional Provider must bill on a separate professional claim (HCFA-1500)

2. Facility- drug must not be included on any facility claim, and added to any DRG or APC charges

3. SCD- must not be purchased at 340B program or be dispensed from 340B program inventory

Reimbursement:

4. Claims bust include the corresponding NDC, units, HCPCs and DX codes

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Rebursement:

1. The SCD is reimbursed at an invoice/ acquisition cost- the charges on the professional claim must equal to the Supplier invoice or the drug
2. If the drug is billed through pharmacy (point of sale), the professional claim will not be reimbursed and will be processed as duplicate

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Coding:

Please check out the following links for more coding info of the 2 drugs that fall under this policy:

Click to access billing-and-coding-guide.pdf

Casgevy Billing and Coding Guide: https://www.casgevyhcp.com/sites/default/files/coding-and-billing-guide.pdf

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Find this type of information useful? Follow my blog for more information. #medicalbilling #medicalcoding #reimbursent

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