CurrentCareSourcePolicy N/A

Transplant DONOR Travel Reimbursement

Describes requirements, eligible expenses, exclusions, and submission instructions for reimbursement of travel-related expenses incurred by transplant donors (not recipients) for members of CareSource in North Carolina.

Policy Summary

PayerCareSource

PolicyTransplant DONOR Travel Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionTransplant services must be pre-authorized and submit the completed donor travel reimbursement form with receipts and a mileage log.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthstimeframe to submit documents from date of service

60 daysmay take up to this long for determination

75 milesminimum travel distance eligible for mileage reimbursement

1traveling companion/caregiver limited to

Donor Travel Reimbursement Coverage Criteria

Donor travel reimbursement criteria

Eligibility, documentation, and excluded expenses for reimbursement of travel-related expenses incurred by transplant donors.

ALL of the following

Submit completed Transplant DONOR Travel Reimbursement Form, all receipts, and a log of miles traveled
Submit documents within 6 months from the date services were received (unless timely filing was prevented)
Transplant services must be pre-authorized to receive travel reimbursement
Mileage reimbursement provided only for travel of more than 75 miles

ALL of the following

Policy Summary

PayerCareSource

PolicyTransplant DONOR Travel Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionTransplant services must be pre-authorized and submit the completed donor travel reimbursement form with receipts and a mileage log.

SourceLink

On This Page

Complete all applicable sections on the form, including the donor full name and home address, donor traveling companion name, place of service where transplant occurred, date of each travel expense, and description/charge for each daily travel expense incurred

ALL of the following

ANY of the following
- Child care
- Mileage for travel within the facility city
- Rental cars, buses, taxis, or shuttle service (except if pre-authorized)
- Frequent flyer miles
- Coupons, vouchers or travel tickets
- Prepayments or deposits
- Telephone calls
- Laundry
- Postage
- Entertainment
- Interim visits to a medical care facility while waiting for the actual transplant procedure
- Travel expenses for donor companion/caregiver
- Return visits for the donor for treatment of a condition found during the evaluation

ALL of the following

Send completed form with receipts and mileage log to CareSource Claims Department - Member Reimbursement P.O. BOX 3607 Dayton, OH 45401-3607 and retain photocopies of bills, receipts, and supporting documentation for personal records

ALL of the following

It may take up to 60 days to receive a determination of your request

Coding and Mileage Thresholds

Not specifiedmixed

No codes listed

Mileage threshold

Minimum eligible mileageGreater than 75 miles

Documentation required for mileageSubmit a log of miles traveled

Receipts requirementAll receipts must be legible and match the information on the form

Pre-authorization and Submission Requirements

Prior Authorization

Prior authorization and documentation submission required for donor travel reimbursement

Transplant services must be pre-authorized for donors to receive travel reimbursement. Submit a completed Transplant DONOR Travel Reimbursement Form (fully and legibly completed), all receipts that match the form, and a log of miles traveled. Documents must be submitted within 6 months from the date services were received; determinations may take up to 60 days. Eligible mileage reimbursement is provided only for travel of more than 75 miles.

Completed Transplant DONOR Travel Reimbursement Form (all applicable sections)
All legible receipts matching the information on the form
Log of miles traveled (mileage reimbursement only for >75 miles)
Submit documents within 6 months from date services were received
Expect up to 60 days for a determination

Definitions

Traveling companion / caregiver (definition)

Allowed companion/caregiver relationshipsParent, spouse, child, sibling, or any person residing with the transplant donor

Form fieldTraveling companion or caregiver name is requested on the form

ScopeDefinition applies specifically to transplant donor traveling companion/caregiver