OAR 410-124-0020
Prior Authorization for All Covered Transplants, Except Cornea and Kidney
(1)
The following services require prior authorization:(a)
All non-emergency transplant services, except for kidney alone and cornea transplants which require prior authorization only if performed out-of-state;(b)
Pre-transplant evaluations provided by the transplant center (for covered transplants only).(2)
The prior authorization request for all covered transplants is initiated by the client’s in-state referring physician or the transplant physician. The initial request should contain all available information outlined in subsection (3) of this rule, below:(a)
For fee-for-service clients, the request should be sent to the Division of Medical Assistance Programs (Division);(b)
For clients enrolled in a coordinated care organization (CCO), requests for transplant services should be sent directly to the CCO.(3)
A completed request for authorization must contain the following information. Failure to submit all the information will delay processing of the request. An optional form (OHP 3084 – Request for Transplant or Transplant Evaluation) is provided on the Transplant Services web page at www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Transplant.aspx for provider convenience in submitting requests:(a)
The name, age, Oregon Health ID number, and birth date of the client;(b)
A description of the medical condition and full ICD-10-CM coding which necessitates a transplant;(c)
The type of transplant proposed, with CPT code;(d)
The results of a current HIV test, (completed within 6 months of request for transplant authorization);(e)
Any other evidence of contraindications for the type of transplant being considered (see contraindications under each transplant type);(f)
The client’s prognosis, with and without a transplant, including estimated life expectancy with and without the transplant;(g)
Transplant treatment alternatives:(A)
A history of other treatments which have been tried;(B)
Treatments that have been considered and ruled out, including discussion of why they have been ruled out.(h)
An evaluation based upon a comprehensive examination completed by a board certified specialist in a field directly related to the condition of the client which necessitates the transplant;(i)
If already done before requesting prior authorization, the results of any medical and/or social evaluation completed by a transplant center should be included in the prior authorization request. The completion of an evaluation by a transplant center before receiving prior authorization from the Division does not obligate the Division to reimburse that transplant center for the evaluation or for any other transplant services not prior authorized.(4)
Prior authorization approval process and requirements:(a)
For clients receiving services on a fee-for-service basis:(A)
After receiving a completed request, the Division will notify the referring physician within two weeks if an evaluation at a transplant center is approved or denied;(B)
A final determination for the actual transplant requires an evaluation by a selected transplant center, which will include:(i)
A medical evaluation;(ii)
An estimate of the client’s motivation and ability, both physical and psychological, to adhere to the post-transplant regimen;(iii)
The transplant center’s assessment of the probability of a successful outcome, based on the type of transplant requested, the condition of the client, and the client’s ability to adhere to the post-transplant regimen; and(iv)
A recommendation using both the transplant center’s own criteria, and the Division criteria.(b)
For Oregon Health Plan (OHP) transplant eligible clients who are in an CCO: Refer to the CCO for approval process and requirements;(c)
The prior authorization request will be approved if:(A)
All Division criteria are met; and(B)
Both the transplant center’s and the specialist’s evaluations recommend that the transplant be authorized; and(C)
The ICD-10-CM diagnosis code(s) and CPT transplant procedure code(s) are paired on the same currently funded line on the Prioritized List of Health Services.(5)
The referring physician, transplant center, and the client will be notified in writing by the Division or the CCO of the prior authorization decision.(6)
Prior authorization of a transplant does not guarantee reimbursement for the services of any provider if, at the time the transplant is performed, intercurrent events have caused the individual’s medical condition to deteriorate to the point at which survival with or without transplant for a period of more than sixty days is unlikely.
Source:
Rule 410-124-0020 — Prior Authorization for All Covered Transplants, Except Cornea and Kidney, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-124-0020.