Overview

The following transplants are covered when prior authorization is obtained and when medically necessary:

• Cornea
• Heart
• Heart and lung
• Intestine
• Kidney
• Kidney and pancreas
• Pancreas
• Liver
• Lung (single or double)
• Allogeneic stem cell transplants 
• Autologous stem cell transplants

All covered transplant services must be provided by a Health Net Transplant Performance Center (Center). Transplant service requests are evaluated on a case-by-case basis and must be prior authorized through Health Net or the delegated participating provider group (PPG).

PPG Procedures

Delegated PPGs use the following procedure for reviewing requests for delegated transplant services:

1.  The treating physician or transplant center (requestor) submits a request for transplant services to the delegated PPG.
2. If Health Net receives a request directly from a treating physician or transplant center for a delegated transplant service, the requestor is referred to the delegated PPG.

The following applies to all non-delegated PPGs

For non-delegated PPG members, all major organ and bone marrow transplant (both allogenic stem cell and autologous stem cell) requests must be submitted by the transplant service provider directly to the Centene Centralized Transplant Unit (CTU) for review. Requests received from the primary care physician (PCP), specialist or PPG will be returned, and the requestor will be informed to have the transplant center submit the request.

A PCP, specialist or non-delegated PPG who identifies a member as a potential candidate for transplant services must provide applicable medical records to a Health Net Transplant Performance Center (Center) for transplant evaluation. The Center must submit a prior authorization request for the evaluation to the Centene CTU through the provider portal, or via fax directly to the CTU at 833-769-1142. On receipt of a request for a transplant, the CTU contacts the Center to request any necessary medical records to complete the clinical review. Once complete medical records are received, a review is performed to establish medical necessity. If approved, the Center is notified and provided an authorization number for the evaluation.

Once a member has completed an evaluation and is approved by the Center for transplant, the Center must submit a prior authorization request for listing to the Centene CTU through the provider portal, or via fax directly to the CTU at 833-769-1142. On receipt of a request for a listing, the CTU contacts the provider to request any necessary medical records to complete the clinical review. Once complete medical records are received, a review is performed to establish medical necessity. If approved, the transplant center is notified and provided an authorization number.

If the request meets medical necessity, but the requesting transplant center is not a Health Net Transplant Performance Center, the member may be redirected to a Health Net Transplant Performance Center.

CAR-T cell therapy, corneal transplant, tissue transplant, pancreatic islet cell auto-transplant after pancreatectomy, or parathyroid auto-transplant after thyroidectomy requests must be submitted directly to Health Net.

It is the member's PCP’s, attending physician’s or the PPG's (as applicable) responsibility to authorize medical care prior to a transplant. This includes maintenance care for the member prior to the transplant.

The transplant program covers the professional and institutional costs of solid organ, cornea and stem cell transplants for members when medically necessary and not considered experimental or investigative.

For transplants deemed to be medically necessary, the transplant case rate for solid organ transplants begins either one day prior to the transplant or the day of the transplant (depending on the Transplant Performance Center). For stem cell transplants, the transplant case rate begins at the onset of the preparative regimen, which may be either high-dose chemotherapy, radiation therapy or a combination. Pre-transplant evaluation services are excluded from the global case rate. This is defined as diagnostic services and specialty consultations required to evaluate a Health Net member for transplant program acceptance as an established candidate for a transplant. Coverage for pre-transplant expenses would be based on the participating physician group (PPG) Division of Financial Responsibility (DOFR) matrix determination as described in the PPG Provider Participation Agreement (PPA), or fee for service as applicable based on the member's plan. If the provider refers a transplant case to a facility that is not a Health Net-designated Transplant Performance Center, the transplant-related claims are processed based on the standard PPG DOFR matrix, not the transplant DOFR matrix.

The following transplant services are covered by transplant case rate contracts:

• Donor searches - Donor searches include outside search and donor procurement services. Unrelated searches and stem cell acquisition are done and priced separately through the National Marrow Donor Program (NMDP) or Stemcyte. Unrelated donor matches may require new, advanced technology using molecular matching. Related donor searches are done by the approved transplant facility. Related or unrelated donor searches are covered on all product lines.
• Transplant event (This phase starts with initiation of the preparative regimen, which may be included: high-dose chemotherapy, radiation therapy or a combination) - The preparative regimen may be performed inpatient or outpatient depending on the transplant facility case protocol. This includes institutional, professional and ancillary services related to the transplant.
• Professional fees - Includes all inpatient and outpatient services beginning at the onset of the preparative regimen prior to stem cell transplants through the case rate period.
• Institutional fees - Includes all inpatient and outpatient services, including room and board, for services beginning with the onset of the preparative regimen with high-dose chemotherapy, radiation therapy or a combination for stem cell transplants through the case rate period as specified by the transplant facility contract.
• Post-transplant services - Includes all institutional, professional, ancillary, and pharmaceutical services required after inpatient discharge, except for those medications covered through the member's outpatient pharmacy benefits. Some exclusions apply based on the transplant facility contract limits.

The following transplant services are covered by a transplant case rate contract:

• Stem cell acquisition and collection or apheresis - Includes all institutional, professional and ancillary services required to retrieve and store stem cells.
• Transplant event - This phase involves initiation of high-dose therapy with chemotherapy, radiation therapy or a combination followed by the stem cell rescue or re-infusion - Includes institutional, professional and ancillary services related to this treatment. High-dose therapy may be performed inpatient or outpatient depending on transplant facility case protocol. The transplant event may be as inpatient or outpatient depending on the transplant facility protocol.
• Professional fees - Includes all inpatient and outpatient services beginning at the onset of high-dose chemotherapy, radiation therapy or combination of these prior to the stem cell transplants through the specified case rate period per transplant facility contract.
• Institutional fees - Includes all inpatient and outpatient services, including room and board, for services beginning with the onset of the preparative regimen with high-dose chemotherapy, radiation therapy or combination of these for stem cell transplants through the case rate period as specified by the transplant facility contract.
• Post-transplant services - Includes all institutional, professional, ancillary, and pharmaceutical services required after inpatient discharge, except for those medications covered through the member's outpatient pharmacy benefits. Some exclusions apply based on the transplant facility contract limits.

The following are covered for solid organ transplants and related services:

• Donor search, organ acquisition or procurement services, histocompatibility services, donor services (for example, identifying prospective donors), and United Network for Organ Sharing (UNOS) fees - Unrelated donor searches are covered across all product lines and require prior authorization from Health Net's transplant care managers before beginning the search.
• Transplant of solid organ:
  • Professional fees - May include inpatient and outpatient services beginning either one day prior to the transplant or the date of transplant (depending on the Transplant Performance Center case rate contract provision) for solid organ transplants through the case rate period. Professional services include:
    • Any and all professional services.
    • Consultations including any services rendered by a transplant surgeon for the transplant operation.
    • Post-operative inpatient care and outpatient care.
    • Assistant surgeon and physician assistant for operation and post-operative care.
    • Anesthesiologist services (professional component).
    • Hepatologist for pre- and post-operative inpatient care.
    • Pathologist (professional component) of clinical and anatomical lab testing.
    • Radiologist for professional component of X-rays.
    • Immunologist for the professional component of histocompatibility.
  • Institutional fees - May include inpatient and outpatient services, including room and board, for services beginning either the day prior to the transplant or the date of transplant (depending on the Transplant Performance Center case rate contract provision) of solid organs through the case rate period.
• Re-transplant - Covered if medically necessary and reimbursed according to the terms of the transplant case rate contract with the transplant performance center facility.
• Transplant-related services during the case rate period - May not be covered under the transplant case rate contract depending on the Transplant Performance Center contract provision. Except for medications covered by a member's outpatient pharmacy benefit, post-discharge care includes all transplant-related care, including inpatient and outpatient services (for example, laboratory, radiology, home health care, and durable medical equipment (DME)), all transplant-related medications, including a medication supply for up to 30 days after discharge. Medications that are transplant-related and covered by the member's outpatient pharmacy benefit are not covered under the transplant case rate.

Post-transplant care for current Health Net members is not covered under the transplant case rate contract if the transplant procedure was not pre-approved by Health Net and performed at a facility that is not a Health Net Transplant Performance Center. The transplant case rate contract does not cover post-transplant care for members who had a transplant prior to their Health Net effective date or outside their Health Net coverage period.

Any transplant considered experimental or investigative is not covered, except as referenced under the Group Exceptions section for members covered under the Federal Employee Health Benefits Program (FEHBP), or when approved through an independent review organization or third-party reviewer.

The following services are not covered under the stem cell transplant case rate contract:

• Non-transplant related services.
• Any chemotherapy or radiation therapy (for example, induction, consolidation or adjuvant) performed prior to high-dose chemotherapy is excluded from the case rate and processed according to the standard PPG Division of Financial Responsibility (DOFR) matrix. If it is determined to be a health plan risk, payment is based on current Health Net Provider Participation Agreement (PPA) rates.

The Health Net transplant program covers transplant services at Health Net Transplant Performance Centers (PDF). If a Transplant Performance Center authorizes and coordinates care for services rendered through the PPG, reimbursement is based on the rates included in the Health Net Provider Participation Agreement (PPA).

Out-of-Area Claims

Health Net is responsible for out-of-area claims for transplant-related services that occur out of the member's typical travel patterns between home and the transplant center in the course of receiving transplant-related services. If these services are not transplant-related and do not meet the out-of-area emergency criteria, the services are the member's responsibility.

Payment for Services Not Related to the Transplant Procedure

If the member requires inpatient or outpatient hospital services for an injury or underlying illness that is not transplant-related, these services are processed according to the PPA with the PPG or service institution.

The following information applies only to participating physician groups (PPGs).

The transplant case rate contract includes the professional and institutional costs of medically necessary, non-experimental and non-investigative solid organ, cornea and stem cell transplants, as well as all transplant-related medications, including a medication supply for up to 30 days after discharge. Health Net covers transplants at its Transplant Performance Centers (PDF). These centers operate transplant programs based on a case rate.

For stem cell transplants, donor searches and charges related to the collection and storage of stem cells may not be included in the case rate. This determination is based on the Transplant Performance Center contract provision.

For solid organ transplants, donor searches and organ acquisitions may or may not be included in the case rate. This determination is based on the Transplant Performance Center contract provision.

The transplant case rate is defined by those services provided during the transplant case rate period. If a member is admitted for any other reason prior to the transplant procedure, services rendered are not included in the transplant case rate.

For transplants determined medically necessary, coverage under the case rate contract begins based on the following:

• For a solid organ transplant, the case rate period begins either one day prior to the transplant procedure or the day of transplant (depending on the Transplant Performance Center contract provision).
• For an outpatient stem cell transplant, the case rate period begins on the day of high-dose chemotherapy or radiation therapy and extends to the transplant admission until the specified case rate period based on the Transplant Performance Center contract provision.
• For an inpatient stem cell transplant, the case rate period begins on the day when the preparative regimen with high-dose chemotherapy, radiation therapy or a combination is initiated and ends on the specified case rate period based on the Transplant Performance Center contract provision.

Case Rate Exclusions

Medical services necessary for the maintenance of the member while waiting for a transplant are subject to the participating physician group's (PPG's) authorization and are not covered under the transplant case rate. These services are processed based on the PPG Division of Financial Responsibility (DOFR) matrix, and reimbursement is based on the rates included in the Health Net Provider Participation Agreement (PPA). For example:

• Services not directly related to transplant care are not covered under the transplant case rate.
• Outpatient pharmacy charges and take-home medications, otherwise covered by the Health Net pharmacy program, are not covered under the transplant case rate.
• Pre-transplant evaluations are not included in the case rate.