Nov. 3, 2026

Background:

High-Cost Clinician-Administered Drugs are certain drugs or biologics approved by the Texas Health and Human Services Commission (HHSC) for separate reimbursement outside of the All-Patient Refined Diagnosis Related Group payment system. These drugs may be billed through a specialty pharmacy, when available, or on a separate outpatient claim.

Special Requirements for Transmitting Claims for HCCAD:

1. The hospital must claim separate payment for the HCCAD on an outpatient claim. HCCAD must not be bundled with any other service.

2. The claim for HCCAD must be separate from any facility/institutional claim the hospital submits for all other hospital services delivered to the member during the same visit. The associated inpatient or outpatient charges with the same date(s) of service are billed separately and remain part of the APR-DRG.

3. The date of administration of the drug should be used on the HCCAD outpatient claim.

4. Along with the members’ name, date(s) of service, and other required information, the HCCAD claim must include:

a. The NDC qualifier of N4 

b. The appropriate 11-digit National Drug Code and corresponding HCPCS code for the drug; and 

c. The number of units of the drug administered to the member that is covered by the claim; and

d. The NDC unit of measurement. There are five allowed values: F2, GR, ML, UN or ME. 

5. Hospitals must submit the invoice of the actual acquisition cost of the drug.

Other Updates:

Blue Cross and Blue Shield of Texas Medicaid will update its Provider Manual(s) and applicable training materials to reflect the instructions issued by HHSC. These updates are expected to be completed within 60 days of this notice. BCBSTX does not anticipate any delays; however, if additional time is needed due to unforeseen circumstances, providers will be notified and updated materials will be published as soon as practicable.

Additionally, we encourage you to review the Texas Medicaid Provider Procedures Manual for more information about HCCAD procedure codes and prior authorization requirements.

If you have questions or need assistance, please reach out to our Medicaid Provider Network Team at 855-212-1615 or email.