CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Transplant Services Payment Policy 01.01.23

Defines Neighborhood Health Plan of Rhode Island reimbursement and billing rules for human organ and stem cell transplant services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business, including donor and recipient billing, covered procedures, exclusions, and coding guidance.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTransplant Services Payment Policy 01.01.23

Policy CodePolicy N/A

Change TypeFormat update; claim submission language updated

Effective Date

Next Review Date

Key ActionBill donor services related to harvesting under the Neighborhood recipient's name and member identification number on the recipient's claim(s).

SourceLink

POLICY UPDATE CHANGES

01/01/2023 Format update; updated claim submission language and coverage information.

10/03/2013 Policy Created.

MultipleCovered Procedure Codes Listed

1 yearDonor care coverage duration

10Commercial donor search limit

Policy summary

This policy defines Neighborhood Health Plan of Rhode Island reimbursement and billing rules for human organ and stem cell transplant services. Covered transplant types include heart, lung (including single, double, lobar), kidney, kidney-pancreas (for members with Type 1 Diabetes only), liver, bone marrow and stem cell; donors may be living or deceased.

The policy aligns with CMS guidelines for donor billing and follows National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and other industry-accepted criteria (e.g., InterQual), as well as Rhode Island EOHHS recommendations and Neighborhood Clinical Medical Policies to determine medical necessity.

Payer scope: applies to Neighborhood Health Plan of Rhode Island for Medicaid excluding Extended Family Planning (EFP), INTEGRITY, and Commercial lines of business. Per policy and CMS guidance, donor harvesting-related services for live donors are covered for up to one (1) year and donor charges should be billed under the recipient's claim. Commercial-specific limitation: donor search expenses for non–blood-related donors are limited to 10 searches.

PayerNeighborhood Health Plan of Rhode Island

Policy TitleTransplant Services Payment Policy

Policy NumberN/A

Effective Date

Last Review2023-01-01

Next Review

Scope SummaryDefines Neighborhood Health Plan of Rhode Island reimbursement and billing rules for human organ and stem cell transplant services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business, including donor and recipient billing, covered procedures, exclusions, and coding guidance.

Coverage criteria and exclusions

General Reimbursement Prerequisites

Services must meet ALL of the following to qualify for reimbursement:

ALL of the following

Medically necessary: Service is medically necessary
Neighborhood may use NCD, LCD, InterQual, RI EOHHS recommendations, and Clinical Medical Policies to determine medical necessity; provider must verify eligibility, coverage, and authorization prior to rendering services.
Medical necessity sources: Medical necessity may be determined using National Coverage Determination (NCD), Local Coverage Determination (LCD), industry-accepted criteria such as InterQual, Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies
Verify eligibility: Provider must verify member eligibility, coverage and authorization criteria prior to rendering services
Refer to Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies.
Ordered by physician: Services must be ordered by a health plan physician

Donor Services Coverage

Covered when ALL of the following are met:

ALL of the following

Live donor harvesting covered: Donor health care services associated with the harvesting of the organ are covered for live donorsup to 1 year per CMS guidelines
Neighborhood follows CMS guidelines; care related to harvesting is covered for up to one (1) year.
Billing under recipient: Per CMS guidelines, donor services are billed under the recipient's claim(s) from the hospital performing the transplant
All donor charges should be submitted under the Neighborhood recipient's name and member identification number.
Coverage limited to procurement-related services: Coverage limited to donor services directly related to organ procurement; services for donors that are not directly related to the organ transplant are excluded

Covered Transplant Services (All Lines of Business)

Covered services related to procurement/recipient/donor when recipient is a member include ANY of the following:

ANY of the following

Donor search expenses: A member's donor search expenses (see coverage limitations)
See Commercial-specific Limitation for search limits.
Donor evaluation: Evaluation and preparation of the donor
Dental exam pre-kidney: Dental exam prior to kidney transplant
Organ transport: Obtaining and transporting donated organs for the member receiving a transplant

Commercial-specific Limitation

Commercial donor search limit: Member's donor search expenses are limited to 10 searches for donors not related by blood10 searches for donors not related by blood

Applies to Commercial line only.

Commercial donor search expense limit10 searches for donors not related by blood

Live donor care coverage duration1 year (per CMS)

CPT / HCPCS coding guidance

Covered CPT/HCPCS Codes (transplant and donor procedures)mixedCovered

32850	Donor pneumonectomy(s) (including cold preservation), from cadaver donor.
32851	Lung transplant, single; without cardiopulmonary bypass.
32852	Lung transplant, single; with cardiopulmonary bypass.
32853	Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass.
32854	Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass.
32855	Backbench standard preparation of cadaver donor lung allograft; unilateral.
32856	Backbench standard preparation of cadaver donor lung allograft; bilateral.
33930	Donor cardiectomy-pneumonectomy (including cold preservation).
33933	Backbench preparation of cadaver donor heart/lung allograft prior to transplantation.
33935	Heart-lung transplant with recipient cardiectomy-pneumonectomy.

1–10 of 70

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Billing, documentation and submission requirements

Billing Rule

Bill donor services under recipient's claim

Per CMS guidelines and Neighborhood policy, donor services related to harvesting must be submitted under the Neighborhood recipient's name and member identification number and billed on recipient's claim(s).

Documentation Required

Maintain medical records to support billed services

Neighborhood may request medical records; documentation must support services billed and medical necessity; Neighborhood follows CMS standards for proper documentation.

Prior Authorization

Verify authorization and eligibility prior to services

Provider must verify member eligibility, coverage, and authorization criteria prior to rendering services. Refer to Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies for authorization and coverage details.

Billing Rule

Timely claim submission

Providers are required to submit complete claims for payment within contractually determined timely filing guidelines and billable services are subject to contractual agreements.

Denial Risk

Claims subject to audit and denial if not supported

All services billed are subject to audit; claims may be denied if documentation, coding, member eligibility, authorization, or contractual requirements are not met.

Key definitions

Live donorAn individual who donates an organ or stem cells while alive; donor's harvesting-related services are covered for up to one year per CMS guidelines.

Document changes

10/03/2013added

Policy Created. Original policy creation date.

01/01/2023revisedLatest

Format update; updated claim submission language and coverage information.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTransplant Services Payment Policy 01.01.23

Policy CodePolicy N/A

Change TypeFormat update; claim submission language updated

Effective Date

Next Review Date

Key ActionBill donor services related to harvesting under the Neighborhood recipient's name and member identification number on the recipient's claim(s).

SourceLink

On This Page

HLA testing: A member's human leukocyte antigen (HLA) testing

Recipient transplant services: Recipient transplant covered services

Includes services listed in coding and transplant coverage sections.

Live donor surgical and recovery: Live donor covered services including surgical intervention and recovery services directly related to donating the stem cells or solid organ to the member

Covered when recipient is a member.