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25.2.2.6 Hospital Transplant Center Approval
In-State Facility Approval Process
All facilities choosing to participate in the Texas Medicaid Transplant Program will be monitored and approved by HHSC. The transplant facility should be approved by Medicare as a transplant center before applying to the Texas Medicaid Program unless the transplant facility is in a designated Children's Hospital. The Texas Medicaid Program will not reimburse for transplants in the hospitals that do not have current approval by HHSC. Exception(s) may be considered if the transplant type is not available in Texas.
All transplant facilities who wish to perform organ transplants for clients of the Texas Medicaid Program must have current certification and be in continuous compliance with the criteria set forth by the Organ Procurement and Transportation Network (OPTN) criteria, receive certification from the United Network for Organ Sharing (UNOS) or the National Marrow Donor Program (NMDP). The Texas Medicaid Program does not approve or reimburse transplants in facilities that are not certified and in "good standing" with these credentialing organizations.
Those facilities whose status of "good standing" has been suspended for any reason by the national credentialing bodies will not be approved by the Texas Medicaid Program to provide transplant services until this status has been restored.
The facility must notify HHSC within three working days of any change in compliance or certification status from UNOS and NMDP. Failure to notify HHSC within three working days of any changes in compliance or certification status may result in disapproval of current and pending transplant requests or recoupment of reimbursement. Submit notification information to:
Texas Health and Human Services Commission
1100 West 49th Street, H-310
Austin, TX 78756
Attn: Medicaid/CHIP Benefits-Transplant Facility Approvals
Out-of-State Facilities
The Texas Medicaid Program requires that all transplant facilities requesting approval to perform transplants for Texas Medicaid clients must provide proof of transplant facility certification. HHSC approval is dependent upon compliance with the transplant facility criteria of the OPTN and certification from the UNOS or the NMDP. In order for the Texas Medicaid Program to pay for an out-of-state transplant, the facility and professional providers must be enrolled as Texas Medicaid providers. The out-of state transplant facilities must submit documentation about relevant transplant facility UNOS or NMDP certification as required by HHSC.
Texas licensed physicians may request prior authorization for transplant services to be performed at out-of-state facilities when the:
• Facilities are nationally recognized as Centers of Excellence.
•Required organ transplants are not available in Texas.
•Services are medically necessary, reasonable, and federally allowable.
•The client is enrolled in the Texas Medicaid Program.
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