CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Major Organ Transplant Services — Coverage Criteria

Defines coverage, authorization, and limits for major organ transplants (living and deceased donor) for Neighborhood Health Plan of Rhode Island members in specified benefit packages.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMajor Organ Transplant Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization from the plan when a plan physician orders transplant services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5Named covered benefit packages

1 yearDonor services billed to recipient's claim (duration)

2Service settings included

listedExcluded transplant types

Coverage Criteria

General coverage conditions

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMajor Organ Transplant Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization from the plan when a plan physician orders transplant services.

SourceLink

On This Page

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Membership and Benefit Package: Member is enrolled in one of the listed benefit packages (RIte Care, Children with Special Health Care Needs, Substitute Care, Rhody Health Partners, Rhody Health Options Phase One).

From Coverage Includes and Benefit Packages.

Order and Authorization: Transplant is ordered by a plan physician and prior authorization is obtained.

Authorization requirement stated.

Covered Organ Types: Major organs including heart, kidney, kidney-pancreas (for Type 1 Diabetes only), liver, bone marrow and stem cell transplants are covered.

List of included organs.

Donor Coverage: For living donors, healthcare services associated with organ harvesting are covered when the recipient is a Neighborhood member and are billed under the recipient's claim per CMS guidelines for up to one year.1 year

CMS-guided donor service billing.

Provider Actions & Billing Rules

Prior Authorization

Prior Authorization Required

Authorization is required for transplant services when ordered by a plan physician. Prior authorization must be obtained before scheduling transplant procedures for members in covered benefit packages (Rhody Health Partners, Rhody Health Options Phase One, Rite Care, Children with Special Health Care Needs, and Substitute Care).

Applies to major organ transplants (heart, kidney, kidney-pancreas for Type 1 Diabetes, liver, bone marrow/stem cell, lungs)
Prior authorization required when ordered by a Neighborhood plan physician

Denial Risk

Authorization and Limited Benefit Package

EFP (Extended Family Planning) members do not have transplant benefits — their benefit package is restricted and transplant services are excluded. Additionally, transplants of the face and hand are considered experimental and are not covered.

EFP members: transplant services excluded
Face and hand transplants: experimental / not covered

Billing Rule

Donor Services Billing and Documentation

For living donor transplants where the recipient is a Neighborhood member, Neighborhood covers the donor's health care services associated with organ harvesting. Per CMS guidelines, donor services related to harvesting are billed under the recipient's claim(s) at the hospital performing the transplant and are covered for up to one (1) year. Documentation should support that the donor services are associated with a Neighborhood member recipient.

Live donor services billed on recipient's claim (hospital)
Coverage period for donor services: up to 1 year per CMS guidelines
Donor services covered only when recipient is a Neighborhood member

Note

Provider Action Checklist

Surface provider actions: obtain prior authorization; verify member benefit package (EFP restrictions); ensure donor services are billed on the recipient’s claim and retain documentation linking donor care to the Neighborhood member recipient. Verify coverage of recipient anti-rejection medications for active members in RIte Care, Substitute Care, CSN or RHP benefit plans.

Obtain prior authorization before transplant scheduling
Confirm member benefit package to confirm transplant eligibility (EFP members excluded)
Bill living donor harvesting services under the recipient's claim and retain documentation
Confirm anti-rejection medication coverage for active recipients in RIte Care, Sub Care, CSN, or RHP

Policy Background

This policy applies to major organ transplant services, distinguishing between living and deceased donors and covering recipient and related donor services across care settings. Covered transplant types include typical major organs (see coverage criteria), and episodes of care may occur in multiple settings including Inpatient (POS 21) and Outpatient (POS 22). Note that certain procedures (for example, face and hand transplants) are considered experimental and are excluded from coverage.

Definitions

Human organ transplant definition

DefinitionHuman organ transplant is the surgical removal of a whole organ from one body and transplanting it to another to replace the recipient's damaged organ; donors may be living or deceased.

Included organsHeart; kidney; kidney–pancreas (for members with Type 1 Diabetes only); liver; bone marrow and stem cell.

ScopeThis benefit summary covers major organ transplants and does not include bone and tissue transplants.

Donor typesOrgan donors can be living or deceased.

Billing note for live donorsFor live donor transplants, donor health care services associated with harvesting the organ are covered and billed under the recipient's hospital claim per CMS guidelines for up to one (1) year.

Post-Transplant Coverage

Anti-rejection medications

Coverage ruleTransplant recipients' anti-rejection (immunosuppression) medications are covered while the recipient is an active member in the listed benefit plans (RIte Care, Substitute Care, Children with Special Health Care Needs, Rhody Health Partners).

Applies toRecipients who remain active members in the specified benefit packages following transplant.

Referenced benefit packagesRIte Care; Substitute Care; Children with Special Health Care Needs (CSN); Rhody Health Partners (RHP).

Related noteCoverage of anti-rejection meds is stated alongside other transplant coverage and conditionally covered services in the transplant benefit summary.

S2140	Cord blood harvesting for transplantation, allogeneic
S2142	Cord blood-derived stem-cell transplantation, allogeneic

OpenPayer

Major Organ Transplant Services — Coverage Criteria

Coverage Criteria

Coding and Billing

Provider Actions & Billing Rules

Policy Background

Definitions

Candidate Organ & Recipient Criteria

Evaluation & Authorization Requirements

Post-Transplant Coverage