23-218 Follow Organ Transplant Referral and Authorization Process to Avoid Delays
Date: 03/10/23
Transplant centers submit requests for authorization to the Centene Centralized Transplant Unit (CTU)
Physicians and other providers must follow the below organ transplant referral and authorization processes for each specified line of business.
Medi-Cal organ transplant process for members under age 21
All transplant services for Health Net* 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 for Medi-Cal members under age 21, as these services are carved out to the CCS program.
Medi-Cal members under age 21 with CCS-eligible conditions who require transplants must be referred to CCS. Health Net assists to ensure timely referral 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.
Medi-Cal organ transplants for members ages 21 and over
All organ transplants are covered under the Health Net Medi-Cal contract. There is no participating physician group (PPG) delegation for Medi-Cal transplant services.
Health Net covers the cost of medically necessary, non-experimental and non-investigative organ and stem cell transplants at Medi-Cal approved, Health Net Transplant Performance Centers (Centers). Service requests are evaluated on a case-by-case basis and must be prior authorized through Health Net.
Medi-Cal referral process for solid organ transplant and bone marrow transplant for ages 21 and over
A PCP, specialist or 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 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 833-769-1141. On receipt of a request for a listing, the CTU contacts the Center or other 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.
Submit CAR-T cell therapy, corneal transplant, tissue transplant, pancreatic islet cell auto-transplant after pancreatectomy, or parathyroid auto-transplant after thyroidectomy requests directly to Health Net.
Medicare organ transplant prior authorization and review procedure
Health Net covers the cost of medically necessary, non-experimental and non-investigative organ and stem cell transplants at Medicare-approved, Health Net Transplant Performance Centers (Centers). Service requests are evaluated on a case-by-case basis and must be prior authorized through Health Net or the delegated PPG.
Delegated PPG process (Medicare)
Delegated PPGs must follow the procedure below for reviewing requests for delegated transplant services:
- The treating physician or transplant center (requestor) submits a request for transplant services to the delegated PPG Utilization Review Committee.
- The PPG Utilization Review Committee reviews and informs the requestor of its determination.
- 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.
Non-delegated PPG process (Medicare)
For non-delegated PPG members, all major organ and bone marrow transplants (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 Medicare-approved, Health Net Transplant Performance Center for transplant evaluation.
The Center must submit a prior authorization request for the evaluation to the CTU through the provider portal, or via fax directly to the CTU using the fax numbers below.
Centers must use these fax numbers to request prior authorization from the CTU:
Type of Medicare plan | Prior authorization fax number |
|---|---|
For members with an individual Medicare plan | 833-769-1143 |
For members with an employer group Medicare plan | 833-769-1142 |
On receipt of a request for a transplant 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 for transplant by the Center, the Center must submit a prior authorization request for listing to the CTU through the provider portal, or via fax directly to the CTU. For individual Medicare plan members, fax to 833-769-1143. For employer group Medicare members, fax to 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.
If the request meets medical necessity, but the requesting transplant center is not a Medicare-approved, Health Net Transplant Performance Center, the member may be redirected to a Medicare-approved, Health Net Transplant Performance Center.
Submit CAR-T cell therapy, corneal transplant, tissue transplant, pancreatic islet cell auto-transplant after pancreatectomy, or parathyroid auto-transplant after thyroidectomy requests directly to Health Net.
Commercial plan organ transplant prior authorization and review procedure
HMO organ transplant process
Health Net covers the cost of medically necessary, non-experimental and non-investigative organ and stem cell transplants at Health Net Transplant Performance Centers (Centers). Service requests are evaluated on a case-by-case basis and must be prior authorized through Health Net or the PPG, based on delegation agreement.
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 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 physician or other 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.
Prior authorization (commercial HMO, PPO and EPO)
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, for HMO and EPO, the delegated PPG.
Delegated PPG process (commercial HMO and EPO)
Delegated PPGs must follow the procedure below for reviewing requests for delegated transplant services:
- The treating physician or transplant center (requestor) submits a request for transplant services to the delegated PPG Utilization Review Committee.
- The PPG Utilization Review Committee reviews and informs the requestor of its determination.
- 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.
Non-delegated PPG process (commercial HMO and EPO)
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 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 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 Center or other 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.
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.
Submit CAR-T cell therapy, corneal transplant, tissue transplant, pancreatic islet cell auto-transplant after pancreatectomy, or parathyroid auto-transplant after thyroidectomy requests 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.
HSP organ transplant process
Refer to the Health Net Transplant Performance Center matrix when referring Health Net members for a transplant procedure. View the matrix in the Provider Library > HSP > Forms and References > Transplant Performance Centers. The matrix lists Centers and programs by region.
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 after logging in to Health Net’s provider portal > Provider Library under Quick Links, or go directly to provider library.
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center by email, by phone or through the Health Net provider portal.
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.