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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 8. Physician : 8.2 Services, Benefits, Limitations, and Prior Authorization : 8.2.49 Organ/Tissue Transplants : 8.2.49.9 Prior Authorization for All Transplants

8.2.49.9
Prior Authorization for All Transplants
It is the requesting physician and facility’s responsibility to receive prior authorization through TMHP Special Medical Prior Authorization.
HHSC or its designee must prior authorize all transplant services provided by facilities and professionals. Documentation supplied with the prior authorization request must address the criteria listed for each type of transplant above, and must be medically necessary, reasonable, and federally allowable.
If prior authorization is not obtained for a solid organ transplant, services directly related to the transplant within the three‑day preoperative and six‑week postoperative period are also denied regardless of who provides the services (e.g., laboratory services, status post visits, radiology services). Claims for transplant clients are placed on active review when the transplant was not prior authorized so that the services related to the transplant can be monitored.
Coverage is limited to one transplant per organ system (or organ systems for combined transplants) per lifetime except for one subsequent transplant because of organ rejection. A subsequent transplant is not included in the prior authorization for the initial transplant; therefore, it must be prior authorized separately.
A transplant request signed by a physician associated with one of Texas Medicaid‑approved transplant facilities is considered for prior authorization after the client has been evaluated and meets the guidelines of the institution’s transplant protocol. Additional documentation may be required, which is addressed in the previous specific organ/tissue information.
Texas Medicaid does not pay for transplants or post-transplant services in a nonqualifying facility, nor are physician charges reimbursed for transplants in a nonqualifying facility.
Benefits are not available for any experimental or investigational services, supplies, or procedures. Expenses incurred by a living donor for transplants will not be reimbursed.
All supporting documentation must be included with the request for authorization. Providers are to send requests and documentation to the following address:
Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357‑B Riata Trace Parkway, Suite 150
Austin, TX 78727
Fax: 1‑512‑514‑4213

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.