News
21-781 Transplant Benefit for Medi-Cal Members
Date: 10/27/21
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
For Medi-Cal, this information applies to Fresno, Kings, and Madera counties.
Submit major organ transplant and corneal transplant requests to the health plan
Per All Plan Letter 21-0151, as part of the California Advancing and Innovating Medi-Cal (CalAIM) initiative to standardize managed care plan benefits, all Medi-Cal managed care health plans are required to cover the major organ transplant (MOT) benefit, including related services such as organ procurement and living donor care.
Effective January 1, 2022, Health Net and CalViva Health will cover and manage MOT, including related services, for adult Medi-Cal members.
For Medi-Cal members under age 21, pediatric transplant services remain a carve-out to California Children's Services (CCS). Transplant service requests must be submitted to the appropriate CCS office. If the CCS program determines that the member is not eligible for the CCS program, but the transplant service is medically necessary, Health Net, on behalf of CalViva Health, will be responsible for authorizing the transplant service, as appropriate.
Delegated participating physician groups
Beginning January 1, 2022, participating physician groups (PPGs) are required to submit requests to the health plan for all MOT-related care and corneal transplants for Medi-Cal members ages 21 and over. There will be no PPG delegation for Medi-Cal transplants.
Covered benefits
For adult members ages 21 and over, Health Net covers the professional and institutional costs of medically necessary MOT and corneal transplants. MOT and corneal transplants require prior authorization and must be performed at a Medi-Cal-approved Center of Excellence (COE) transplant program.
Prior authorization
A primary care physician (PCP), specialist, PPG or facility who identifies a member as a potential candidate for transplant services must submit a request for a transplant evaluation to Health Net for prior authorization.
Services requiring prior authorization include, but are not limited to:
- Transplant evaluation.
- Transplant consult visits.
- Donor search.
- Transplant procedure.
Providers must submit clinically relevant information for medical necessity review with the prior authorization request. Fax authorization requests to the Transplant Team at 833-769-1141.
Additional information
Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library, located on the provider website.
Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.
1 www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2021/APL21-015.pdf.