CurrentAnthemPolicy N/A

Transplant Services Notification and Precertification (Attachment Form A1)

Governs notification, precertification, and administrative submission requirements for transplant services (solid organ and bone marrow/stem cell) for Anthem members; affects providers, transplant hospitals, and plan representatives involved in transplant care and billing.

Policy Summary

PayerAnthem

PolicyTransplant Services Notification and Precertification (Attachment Form A1)

Policy CodePolicy N/A

Change TypeAdministrative update

Effective DateN/A

Next Review DateN/A

Key ActionProviders must precertify and verify member eligibility and submit the signed Attachment Form A1 with the bundled/global claim and CME Attachment C or D as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2transplant types listed

3cell source options

4donor type options

A1submission form

Coverage Criteria and Administrative Attestations

Administrative coverage attestation

Covered when ALL of the following administrative attestations are provided:

Administrative attestations: The patient meets Anthem medical necessity guidelines for the noted transplant; precertification has been obtained and eligibility verified prior to beginning CME Transplant Services; hospital will submit a bundled/global claim with Attachment Form A1 and the CME Attachment C or D as applicable; the hospital will collect any applicable coinsurance, deductibles, and co-payments.

This node reflects administrative requirements documented on the form.

Coverage criteria: None explicitly listed on the form. The Attachment Form A1 functions as an administrative notification and attestation that the patient "meets the medical necessity guidelines of Anthem" for the noted transplant and documents required administrative items (hospital, contact, and billing instructions) rather than listing clinical eligibility thresholds.

Provider Responsibilities, Precertification, and Submission

Policy Summary

PayerAnthem

PolicyTransplant Services Notification and Precertification (Attachment Form A1)

Policy CodePolicy N/A

Change TypeAdministrative update

Effective DateN/A

Next Review DateN/A

Key ActionProviders must precertify and verify member eligibility and submit the signed Attachment Form A1 with the bundled/global claim and CME Attachment C or D as applicable.

SourceLink

On This Page

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Prior Authorization

Prior Authorization Required

Providers must contact the plan to verify continued member eligibility and obtain authorization prior to transplant. Confirm precertification and eligibility before beginning Centers of Medical Excellence (CME) transplant services.

Contact the plan at the number listed on the member’s ID card or the plan-specific transplant contact before scheduling the transplant.
Verify member eligibility and benefits, including any applicable coinsurance, deductibles, and copayments.

Step Therapy

Not Applicable — Clinical Step Therapy

This document focuses on notification and precertification requirements for transplant services rather than clinical step therapy protocols. Step therapy/clinical step protocols are not applicable to this transplant notification process.

Documentation Required

Submission and Signature Required

Print and sign the completed Attachment Form A1: Transplant Services Notification Form. Submit the signed form along with the bundled documentation (including the CME Attachment C or D when applicable) and any required supporting medical records per plan instructions.

Hospital must submit the bundled global claim and include Attachment Form A1 and CME Attachment C or D as applicable.
Collect and remit any applicable member coinsurance, deductibles, and copayments at the time of service.
Reconfirm plan claim contact information prior to submitting the bundled global claim.

Denial Risk

Denial Risk for Failure to Precertify

Failure to precertify and verify eligibility may result in lack of authorization for the transplant and potential denial of coverage or member financial liability.

If authorization is not obtained prior to the transplant, the plan may deny payment for services.
Hospitals should reconfirm the plan claim contact and verify authorization status to mitigate denial risk.

Transplant Candidate Identification Fields

Candidate identification fields

Form fields to identify the transplant candidate and procedure; no clinical eligibility thresholds are specified on the form itself.

Candidate identification: Provider must supply patient diagnosis and transplant type. For bone marrow/stem cell transplants indicate type (autologous, allogeneic, 'mini' allogeneic, tandem #1, tandem #2), cell source (bone marrow, peripheral blood stem cell, cord blood), and donor relationship/match status if allogeneic (related, unrelated, matched, mismatched). For solid organ transplants indicate organ type (initial transplant or re-transplant) and donor type (cadaveric or living donor).

Administrative identification only; clinical eligibility is referenced generically as meeting Anthem medical necessity guidelines.

Evaluation and Authorization Requirements

Prior Authorization

Evaluation — precertification and eligibility check

Providers must contact the plan for precertification and to verify continued eligibility for medical benefits prior to beginning CME Transplant Services.

Obtain authorization from the authorized plan representative whose contact is listed on the form before starting services.

Center Participation and Billing Agreements

Note

Center requirements and billing rates

Refer to the Centers of Medical Excellence Hospital Participation Agreement for eligible transplant services and applicable global/outlier rates; hospitals must submit bundled, global claims and follow CME participation terms.

All eligible transplant services and global/outlier rates are listed in the CME Hospital Participation Agreement.
Hospital must submit a bundled, global claim (including CME Attachment C or D) and a copy of Attachment Form A1.

Billing: Bundled Global Transplant Claim Submission

Bundled global transplant claim submission

Required billing submissionHospital must submit a bundled, global claim that includes the CME Attachment C or D and a copy of Attachment Form A1 (Transplant Services Notification Form).

Form to includeCopy of Attachment Form A1 (Transplant Services Notification Form) must accompany the bundled/global claim.

Attachments referencedInclude CME Attachment C or D as applicable for the transplant service billed.

Collect member cost-sharingHospital is to collect any applicable coinsurance, deductibles, and co-payments when submitting the bundled/global claim.

Confirm claim contactPlease reconfirm the plan claim contact information prior to submitting the bundled global claim.

Definitions and Transplant Type Options

Autologous

DefinitionAutologous: patient’s own stem cells used for transplant (checkbox option on the form).

Context on formListed as a transplant type option under Bone marrow stem cell section to identify the procedure type.

Related fieldsCell source and donor fields are present elsewhere on the form but not required to describe autologous beyond the checkbox selection.

Allogeneic

DefinitionAllogeneic: donor stem cells used for transplant (checkbox option on the form).

Donor relationship optionsForm lists donor options for allogeneic: Related or Unrelated.

Donor match optionsForm lists donor match status options: Matched or Mismatched.

Initial transplant / Re-transplant

DefinitionInitial transplant: indicates the procedure is the patient’s first transplant (checkbox option on the form).

DefinitionRe-transplant: indicates the procedure is a repeat transplant (checkbox option on the form).

Form sectionListed under Solid organ section as part of Organ type to identify whether initial vs re-transplant.

Form Background and Captured Clinical Classifications

The form captures basic clinical classification and administrative details for transplant services. For bone marrow/stem cell transplants it records cell source and donor relationship/match options; for solid organ transplants it records whether the procedure is an initial transplant or re-transplant and whether the donor is cadaveric or a living donor. The form also documents the transplant hospital, contact information for precertification and case management, and contains an attestation that the patient meets Anthem medical necessity guidelines. Finally, it instructs the hospital to submit a bundled, global claim (including the CME Attachment C or D) and a copy of Attachment Form A1 and to collect any applicable member cost-sharing.