On November 1, 2017, the Centers for Medicare & Medicaid Services (CMS) issued its 2018 Outpatient Prospective Payment System “OPPS” Final Rule, CMS CY2018 OPPS Final Rule, which finalized the Medicare Part B payment for certain drugs acquired through the 340B Program.

 

As appropriate, the 340B Program requires drug manufacturers to provide outpatient drugs to eligible health care organizations and covered entities at significantly discounted prices.

 

As described in the Final Rule, CMS established two new modifiers to identify 340B drugs – the “JG” and “TB” modifiers. Beginning January 1, 2018, affected entities were required to report these modifiers on outpatient claims for certain separately payable drugs or biologicals that are acquired through the 340B program and administered or dispensed to patients.

 

Beginning April 1, 2019, for our Commercial lines of business, Anthem Blue Cross and Blue Shield will require that all facilities eligible for the 340B Program bill these modifiers on all outpatient claims impacted by these modifiers.

 

These facilities are excluded from this billing requirement:

  • Sole community hospitals (“SCHs”)
  • Children’s hospital
  • PPO-exempt cancer hospitals
  • Critical access hospitals (“CAHs”)
  • Drugs administered/dispensed in non-excepted hospital off-campus outpatient departments (“HOPDs”)



Featured In:
January 2019 Anthem Missouri Provider Newsletter