North Carolina Medicaid: Billing guidance for cell and gene therapy treatments
Effective immediately, health care providers in North Carolina can participate in the Cell and Gene Therapy (CGT) Access Model through its Cooperative Agreement funding program. Participation in the CGT program provides eligible Medicaid enrollees with timely access to cell and gene therapy at reduced health care costs through the state’s Medicaid program.
Prior authorization requirements
To comply with the North Carolina Medicaid Clinical Coverage Policy 1S-13, you must obtain prior authorization before providing CGT treatment to UnitedHealthcare Community Plan members. You may not bill members for services provided without prior authorization or for those denied in a claim.
Please take the following steps to submit a request to UnitedHealthcare for the CGT drugs listed in the chart below:
| Drug name | HCPCS code |
|---|---|
| Hemgenix® | J1411 |
| Luxturna® | J3398 |
| Elevidys® | J1413 |
| Roctavian® | J1412 |
| Zynteglo® | J3393 |
- Sign in to the UnitedHealthcare Provider Portal with your One Healthcare ID. If you don’t have a One Healthcare ID, register now.
- From the left-hand tabs, select Prior Authorizations & Notifications
For training, view our Prior Authorization and Notification interactive guide.
Contact Optum Transplant Services at 888-802-1802 to initiate the prior authorization process for the drug therapies listed below:
| Drug name | HCPCS code |
|---|---|
| Casgevy® | |
| LenmeldyTM | |
| Lyfgenia® | |
| Skysona® | |
| Zynteglo® |
Billing guidance
Refer to the UnitedHealthcare Provider Manual for North Carolina (Chapter 11) and the Clinical Coverage Policy 1S-13 for detailed billing instructions.
Questions? We're here to help.
Connect with us through chat 24/7 in the UnitedHealthcare Provider Portal.
PCA-1-25-02560-C&S-NN_01162026
