Reminder: Major Organ Transplant Carve-In
| Date: | January 25, 2022 |
| To: | HPSJ Primary Care Providers, Specialists, Hospitals and Facilities |
| Provider Alert Type: | Regulatory |
| From: | Health Plan of San Joaquin (HPSJ) |
| Subject: | Reminder: Major Organ Transplant Carve-In |
| Business: | Medi-Cal |
As we begin 2022, we are providing a reminder of the new benefit changes in this year. Effective January 1, 2022, Health Plan of San Joaquin (HPSJ) will cover the Major Organ Transplant (MOT) benefit for adult and pediatric (non- California Children’s Services CCS) transplant recipients and donors, including related services such as organ procurement and living donor care. HPSJ will be required to cover major organ transplants such as bone marrow, heart, liver, lung, and simultaneous kidney pancreas.
Health Plan of San Joaquin will provide authorization, referral, and coordination to the delivery of the MOT benefit and all medically necessary services associated with MOTs, including, but not limited to, pre-transplantation assessments and appointments, organ procurement costs, hospitalization, surgery, discharge planning, readmissions from complications, post-operative services, medications not otherwise covered originally by current contractual agreements, and care coordination for transplants under HPSJ responsibility. HPSJ will also cover all medically necessary services for both living donors and cadaver organ transplants. Health Plan of San Joaquin may only authorize MOTs to be performed in approved transplant programs located within a hospital that are CMS and Medi-Cal approved Centers of Excellence (COE).
As part of the MOT carve in, HPSJ will also be required to authorize appropriate nonemergency medical transportation (NEMT), non-medical transportation (NMT) services, and related travel expenses and lodging for transplant recipients and living donors.
As a reminder if a member is identified for MOT services, a prior authorization should be submitted to HPSJ. HPSJ will assess and make a determination on services to be rendered. All Plan Letter 21-015 and Attachment 2 provide further details on covered benefits, current enrollment and care coordination requirements, and transplant programs that meet DHCS criteria. Information on the MOT benefit is also included within the HPSJ provider manual pages 21-22 at: HPSJ Provider Manual.
If you have questions, please contact HPSJ’s Case Management Team at 209.942.6352 or Customer Services Team at 1.888.936.PLAN (7526).