22-086 Major Organ Transplant is a Covered Benefit by the Health Plan

Date: 01/25/22

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.

Contact Health Net directly with your transplant questions and prior authorization requests

As a reminder, starting January 1, 2022, Medi-Cal Managed Care Plans cover major organ transplant (MOT) for recipients and donors, including related services, such as organ procurement and living donor care. Health Net will authorize, refer and coordinate the delivery of MOT benefit and all medically necessary services associated with MOTs.

Most pediatric transplants will qualify as California Children's Services (CCS)-eligible conditions and will continue to be arranged and authorized by CCS.

Reference materials

For more details on this benefit change, refer to Department of Health Care Services (DHCS) APL 21-015, Attachment 2 (PDF).

Refer to provider update 21-779, Transplant Benefit for Medical Members, for more information on how to request prior authorization. The provider update and Outpatient California Medi-Cal Prior Authorization Form is available in the Provider Library. Fax authorization requests to the Transplant Team at 833-769-1141.

Additional information

If you have questions regarding the information contained in this update, contact the Health Net Medi-Cal Provider Services Center within 60 days at 800-675-6110.