Claims & Payment Policy (#150): 340B Drug Payment Reduction Policy

Effective January 1, 2018, the Centers for Medicare & Medicaid Services (CMS) established two new Healthcare Common Procedure Coding System (HCPCS) Level II modifiers – JG and TB – to identify 340B-acquired drugs.

Modifier JG must be used for drugs or biologicals acquired with 340B drug pricing program discount

Modifier TB must be used for drugs of biologicals acquired with 340B drug pricing program discount, reported for informational purposes.

Your facility has a provider contract with WellCare Health Plans, which uses CMS’ Outpatient Prospective Payment System (OPPS) methodology to determine reimbursement for Medicaid outpatient services.

WellCare follows CMS’ payment rules and policy to administer this methodology including the annual inflationary adjustment. Therefore, as a provider who has contracted for this method of reimbursement from WellCare, you are expected to follow CMS billing and coding requirements including the use of the JG or TB modifier as appropriate for 340B acquired drugs or biologicals. Your entire claim may be denied if you do not use these modifiers.

Providers will be able to submit a corrected claim going back to 1/1/2018 for claims affected by this change

If you have not been appropriately using these modifiers, please adjust your billing practices to include their use. Based on our findings, WellCare may conduct recovery audits to determine if dollars are potentially due to WellCare.

For more information, please review the complete policy found on the Claims page under Payment Policies. If you have any questions, please contact you hospital service specialist.