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The purpose of this bulletin is to notify providers of updated billing instructions related to certain long-acting injectables. This is an update to a previous bulletin.

In accordance with Item 288.MMMMM. of the 2025 Appropriation Act, effective July 1, 2025, the Department of Medical Assistance Services (DMAS) shall amend the state plan for medical assistance services to include a provision for payment of medical assistance for FDA-approved, long-acting injectable (LAI) or extended-release medications administered for a serious mental illness or substance use disorder in any hospital emergency department or hospital inpatient setting. This payment shall be unbundled from the hospital daily rate.

See attached billing instructions for the specific procedure codes.  

While this change is effective July 1, 2025, the ability for hospitals to bill this item as a separate claim for the LAI was not available until July 27, 2025.  Hospitals may have chosen one of the following approaches for dates of service beginning July 1, 2025, through July 27, 2025:

1. Hold inpatient and outpatient claims that contain one of the approved LAI drugs until July 27, 2025, to allow for correct claims processing and new billing instructions OR

2. Exclude the LAI code when submitting the inpatient or outpatient claim.  Then hospitals can submit a separate claim for the LAI on or after July 27, 2025. 

DMAS and its contracted Managed Care Organizations (MCOs) are diligently working to implement the new LAI payment structure set forth in the 2025 Appropriations Act. As this structure is legislatively mandated and will be incorporated into the FY2026 Cardinal Care Managed Care (CCMC) capitation rates, MCOs are also required to change the reimbursement structure.  The MCOs may need up to 60 days from July 27, 2025, to finish updating their systems with the new billing structure. The MCOs will inform their providers of the best way to bill for these services once their systems are updated. 

Appeals Information

If you believe an error was made for payment rates or totals, you can file an appeal.  The appeal must be filed with the DMAS Appeals Division through one of the following methods: 

• Through the Appeals Information Management System at https://www.dmas.virginia.gov/appeals/. From there you can fill out an informal appeal request, submit documentation, and follow the process of your appeal. 

• Through mail, email, or fax.  You can download a Medicaid Provider Appeal Request form at https://www.dmas.virginia.gov/appeals/. You can use that form or a letter to file the informal appeal.  The appeal request must identify the issues being appealed. The request can be submitted by:  

  • Mail or delivery to: Appeals Division, Department of Medical Assistance Services, 600 E. Broad Street, Richmond, VA 23219; 

  • Email to appeals@dmas.virginia.gov; or 

  • Fax to (804) 452-5454. 

The appeal must be received by the DMAS Appeals Division within 30 days of the payment rate or total being published by DMAS. The notice of appeal is considered filed when it is date stamped by the DMAS Appeals Division.  The normal business hours of DMAS are from 8:00 a.m. through 5:00 p.m. on dates when DMAS is open for business. Documents received after 5:00 p.m. on the deadline date shall be untimely.

FDA Approved Long-Acting Injectables (LAI) or Extended-Release medications:

DMAS covers LAI’s provided during inpatient or outpatient hospital services. The reimbursement for the LAI will be a separate payment and will not be included in the All Patient Refined Diagnosis Related Grouper (APR-DRG) or Enhanced All Patient Group (EAPG) reimbursed to the Facility. 

Specific LAI Procedure Codes to be covered for separate facility reimbursement are:

• J0578: Brixadi (7-28 days)

• Q9991: Sublocade (less than or equal to 100mg)

• J2426: paliperidone palmitate (Invega Sustenna)

• J0401: aripiprazole, extended-release (Abilify Maintena)

• Q9992: Sublocade (>100mg)

• J2315: naltrexone, depot form (Vivitrol)

• J2794: risperidone (Risperdal Consta)

• J2798: risperidone (Perseris)

Prior authorization is not required on any of the above codes.

Hospitals participating in the 340B drug pricing program must conform to the program’s billing requirements. 

Hospitals will have the ability to bill the following LAI Procedure Codes as a separate claim on a future date. The effective date for separate billing of these codes will be forthcoming in a future bulletin.

• J1943: aripiprazole lauroxil (Aristada Initio)

• J1944: aripiprazole lauroxil (Aristada)

• J0402: aripiprazole (Abilify Asimtufii)

• J2427: paliperidone palmitate (Invega Hafyera or Invega Trinza)

• J2428: paliperidone palmitate (Erzofri)

• J2801: risperidone (Rykindo)

• J2799: risperidone (Uzedy)

• J2358: olanzapine (Zyprexa Relprevv)

• J1631: haloperidol decanoate (Haldol Decanoate)

• J2680: fluphenazine decanoate (Prolixin Decanoate)

• J0577: Brixadi (< 7 days)

Billing Process for Medicaid, FAMIS and Temporary Detention Orders Fee-For-Service:

In order to receive an LAI payment that is separate from the APR-DRG or EAPG payment, hospitals must submit the appropriate claims.

For Inpatient hospital Claims:

Hospitals will need to submit two UB-04 claims. The facility will receive two separate payments. 

The first inpatient claim (bill type 011x) will be for the inpatient hospitalization and all ancillary charges EXCEPT for one of the above listed HCPCS codes. This claim will be reimbursed via APR-DRG methodology. 

The second inpatient claim will be an outpatient claim (bill type 013x) for the LAI procedure  code only and contain this information:

• Number of units 

• LAI HCPCS code (listed above) and 

• National Drug Code (NDC) for the LAI. 

• Charge amount

       The second inpatient claim will be reimbursed via the reference file fee. 

For Outpatient Hospital Claim:

Hospitals will need to submit two UB-04 claims. The facility will receive two separate payments. 

The first outpatient claim (bill type 031x) will be for the outpatient hospitalization and all ancillary charges EXCEPT for one of the above listed HCPCS codes and will be reimbursed via EAPG methodology. 

The second inpatient claim will be an outpatient claim (bill type 013x) for the LAI only and contain only this information:

• the applicable pharmaceutical revenue code (025x and/or 063x),
  • Number of units 

  • LAI HCPCS code (listed above) and 

  • National Drug Code (NDC) for the LAI. 

  • Charge amount

The second outpatient claim will be reimbursed via the reference file fee. 

There is a potential for the provider to submit an additional outpatient claims (bill type 013x) should the member receive a LAI that is for Mental Health diagnosis and one for substance abuse diagnosis.  Each will be reimbursed separately and not deny for duplicate claim if 2 different procedure are billed.     

For Medicare Crossover Claims Part A or B:

Provider’s will need to determine if Medicare paid any dollars on the LAI procedure codes.  If Medicare did not, then the provider can bill DMAS for the LAI.

Hospitals will need to submit two UB-04 claims. The facility will receive two separate payments. 

The first Crossover claim from Medicare (bill type 011X or  031x) will be for the hospitalization services and all ancillary charges will be reimbursed via EAPG methodology or the actual coinsurance and or deductible billed.  The billing instructions for Medicare Crossover claims has not changed nor the reimbursement methodology. 

The second claim if appropriate would be billed as Fee for service (bill type 013X) claim for only the LAI that was not covered by Medicare (not a covered drug or bundled into their payment methodology with no payment for actual drug).

The LAI line should include ONLY:

• the applicable pharmaceutical revenue code (025x and/or 063x),
  • Number of units 

  • LAI HCPCS code (listed above) and 

  • National Drug Code (NDC) for the LAI. 

  • Charge amount

The second outpatient claim will be reimbursed via the reference file fee. 

To avoid disruption to claims payment through FFS and the MCOs providers must periodically check the DMAS provider portal, also known as the Provider Services Solution (PRSS), to ensure that the provider's enrollment, contact information, and license information is up to date, for all of the provider's respective service locations. Under federal rules, MCOs and DMAS are prohibited from paying claims to network providers who are not enrolled in PRSS. Additional information is provided on the MCO Provider Network Resources webpage and includes links to resources, tutorials and contact information to reach Gainwell with any provider enrollment or revalidation related questions.  Dental providers should continue to enroll directly through the DMAS Dental Benefits Administrator, DentaQuest.