All transplant services for Medi-Cal members under age 21 are coordinated through California Children's Services (CCS). Health Net is not responsible for payments related to any transplant or post-transplant care, as these services are carved out to the CCS program.

A primary care physician (PCP) or specialist who identifies a member as a potential candidate for transplant services must submit a referral to the appropriate CCS program office and request prior authorization for a pre-transplant evaluation at a CCS-approved facility. If the CCS program office deems the member to be a potential candidate, the transplant physician must submit a Service Authorization Request (SAR) in a timely manner to the appropriate CCS program office and coordinate services with the CCS case manager. If the CCS program determines that the member is not eligible for the CCS program, but the transplant service is medically necessary, Health Net will be responsible for authorizing the transplant service, as appropriate.

Subject to prior authorization, all transplants, as well as all pre- and post-operative transplant-related costs, not limited to evaluation, hospitalization, transportation, and drugs that are not covered by Medi-Cal Rx, are covered under the Health Net Medi-Cal contracts. There is no PPG delegation for Medi-Cal transplants.

Health Net covers the cost of medically necessary, non-experimental and non-investigative organ and stem cell transplants at a Medi-Cal approved, Center of Excellence (COE) transplant program which operates within a hospital setting.

Health Net must provide prior authorization for requests for transplant services on an expedited, 72-hour basis, or less if the member’s condition requires it or if the organ or bone marrow the member will receive is at risk of being unusable due to any delay in obtaining prior authorization or delay in obtaining the organ or bone marrow.

A PCP, specialist or participating physician group (PPG) who identifies a member as a potential candidate for transplant services must provide applicable medical records to a Medi-Cal approved, Health Net Transplant Performance Center (Center) for transplant evaluation.

The Center must submit a prior authorization request for the evaluation to the Centene Centralized Transplant Unit (CTU) through the provider portal, or via fax directly to the CTU at 833-769-1141. On receipt of a request for an evaluation, 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 833-769-1141. 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 Center is notified and provided an authorization number.

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. The CTU reviews all solid organ and stem cell transplants including human leukocyte antigen (HLA) typing for stem cell, donor search and stem cell harvest and collection.

Refer to the Prescription Drug Program topic for additional information about coverage for immunosuppressive medications following a Medi-Cal approved transplant.