Published: July 29, 2022
Last modified: Jan. 11, 2023
Updated to include information about the implementation of new CMS 340B rates.
On Dec. 2, 2022, we implemented the Centers for Medicare & Medicaid Services (CMS) new 340B rates in our systems, which they published on Oct. 18, 2022. CMS continues to require the modifiers JG or TB for 340B program medication purchases.
Are you a non-exempt 340B Medicare Advantage health care facility or hospital? If so, to receive accurate claim payments involving separately payable, Outpatient Perspective Payment System (OPPS) drugs and biologics with status indicator K, UnitedHealthcare requires 1 of 2 things:
Claim review and notification begins July 23
Beginning July 23, 2021, if a claim for a status indicator K drug is received without the JG modifier and an attestation was not completed for a provider who is not exempt from the 340B program, UnitedHealthcare will assume the drug was purchased through the 340B program and adjust the claim to provide reimbursement at the discounted 340B rate of average sales price (ASP) minus 22.5%.
If you are set up to receive Smart Edits, within 24 hours of claim submission, you will receive a message on your 277CA clearinghouse report indicating the claim may be subject to 340B coding and billing requirements.
Options to modify your claim
If you receive a Smart Edit notification, you have 2 choices to modify your original claim submission.
1. If you purchased the drug or biologic through the 340B program: Update and resubmit the claim with the JG modifier as follows:
2. If you did not purchase through the 340B program: Attest that the drug or biological was not purchased through the 340B program as follows:
If the JG modifier or attestation is not provided
If you submit 340B claims without the JG modifier or attestation, payment for the 340B drug will be at the discounted rate of ASP minus 22.5%. Your provider remittance advice (PRA) will indicate that the claim was paid with a 340B program payment discount.
In the future
Please adjust your billing process to include the JG modifier on appropriate claims or provide an attestation when drugs or biologics are purchased outside of the 340B program. Doing so helps ensure prompt and accurate claim processing.
Other 340B updates and reminders
We're here to help. If you have any questions regarding the use of 340B modifiers, please visit the Contact Us page.