MedicaidPrior AuthMedium impact
North Carolina Medicaid: Billing guidance for cell and gene therapy treatments
UnitedHealthcare·NC · Oncology, Hematology, Ophthalmology +1 more·State news
Effective date
Feb 11, 2026
We identified it
Mar 1, 2026
Summary
North Carolina Medicaid now allows providers to participate in the Cell and Gene Therapy (CGT) Access Model, providing eligible Medicaid enrollees access to cell and gene therapy treatments at reduced costs. Prior authorization is required for all CGT treatments through UnitedHealthcare Community Plan, with specific billing procedures for different drug therapies.
Action Required
Immediately: Billing team must obtain prior authorization before providing any CGT treatments to UnitedHealthcare Community Plan members. For drugs J1411 (Hemgenix), J3398 (Luxturna), J1413 (Elevidys), J1412 (Roctavian), and J3393 (Zynteglo), submit prior auth requests through UnitedHealthcare Provider Portal. For Casgevy, LenmeldyTM, Lyfgenia, Skysona, and Zynteglo, contact Optum Transplant Services at 888-802-1802. Do not bill members for services provided without prior authorization as claims will be denied.