Physician-Administered Drug (PAD) Billing and Payment Requirements
| Date: | April 29, 2026 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Physicians, Clinics, and Hospitals |
| Type: | Informational/Educational |
| Subject: | Physician-Administered Drug (PAD) Billing and Payment Requirements |
| Business: | Medi-Cal Managed Care |
The purpose of this alert is to reminder providers about physician-administered drugs (PADs) and provide resources to help ensure accurate billing.
Definitions:
A physician-administered drug (PAD) is any covered outpatient drug provided or administered to a member (not self-administered by a member or their caregiver) and billed by a medical provider. Most PADs are covered under Medi-Cal as a medical benefit, though a small number of PADs are covered under Medi-Cal as a pharmacy benefit, through Medi-Cal Rx.
Coverage:
A list of PADs that are eligible for coverage and reimbursement by Health Plan is available on Health Plan’s website through the link below (see “HPSJ-MVHP Medical Drug Benefit List of Physician Administered Drugs”).
https://www.hpsj.com/benefits-and-services/medical-drug-benefit/
Billing:
To help ensure timely and accurate payment, providers must submit claims for PADs in accordance with the Medi-Cal billing guidelines below.
- Physician-Administered Drugs (PADs) Overview: https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/89759661-7F1A-41BA-A766-F25DA88E934F/physicianover.pdf?access_token=6UyVkRRfByX TZEWIh8j8QaYylPyP5ULO
- Physician-Administered Drugs – NDC:
- Physician-Administered Drugs – NDC: CMS-1500 Billing Instructions: https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/8CDFCCFF-FE4D-40DD-8DD4-2AC1804B6D97/physicianndccms.pdf?access_token=6UyVkRRf ByXTZEWIh8j8QaYylPyP5ULO
- Physician-Administered Drugs – NDC: UB-04 Billing Instructions: https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/3A12BDE9-4CD8-438C-9D41-0AA49E2DF5E2/physicianndcub.pdf?access_token=6UyVkRRfByX TZEWIh8j8QaYylPyP5ULO
Payment:
In accordance with these guidelines, the reimbursement paid to medical providers submitting medical claims for administering a PAD is separate from the cost of the PAD itself – the administration fee is paid only once for each PAD administered. Subsequent units billed have the administration fee subtracted from the reimbursement rate. Medi-Cal maximum allowable reimbursement rates set forth by DHCS for PADs are available at the link below (see “Medi-Cal Maximum Allowable Reimbursement Rates for Physician-Administered Drugs”).
https://mcweb.apps.prd.cammis.medi-cal.ca.gov/rates?page=1&tab=rates
The one‑time injection administration fee is applied once per administration –meaning once per distinct dose/encounter/unique date of service – not once per member lifetime. When there are separate administrations on the same date of service, providers should bill each administration on its own claim line and use modifier XE for each additional same‑day administration to help ensure accurate payment.
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org
