Solid organ transplant prior authorization form
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A prior authorization request form to be completed by providers seeking authorization for solid organ transplant services (listing, admission, and transplant procedures) for Priority Health members. It captures member, diagnosis, transplant type, dates, provider and facility identifiers, and notes that Priority Health's transplant policy #91272 applies for certain organs.
No material clinical or coverage changes — this is an administrative prior authorization form; no substantive policy changes identified.
Document overview
This is Priority Health's prior authorization request form for solid organ transplant services. It is used to request review and authorization for organ transplant listing, admission, and transplant procedures.
For certain organs (Liver, Islet Cell, Intestinal, Small Bowel / Liver, Multivisceral) Priority Health's clinical criteria in Transplantation of Solid Organs medical policy #91272 must be met in addition to the transplanting institution's selection criteria.
When prior authorization is reviewed
Form completion and review conditions
Prior authorization will be reviewed when ALL of the following form fields are completed and documentation may be requested:
ALL of the following
- Member identifying information completed (last name, first name, Priority Health ID#, date of birth)
- Organ(s) requested indicated
- Transplant evaluation information provided (HLA typing, listing start date, date of service, primary diagnosis description, diagnosis code(s))
- Transplant listing: indicate whether transplant institution's selection criteria has been met and which organ (Kidney, Heart, Lung, Pancreas Transplant Alone (PTA), Pancreas after Kidney (PAK), Simultaneous Pancreas-Kidney (SPK), Liver, Islet Cell, Intestinal, Small Bowel / Liver, Multivisceral)
- Admission for transplant information provided (date of admission, date of transplant, primary procedure description, procedure code(s) - CPT)
- Requesting provider and facility information: Requesting provider and facility contact and identifier information provided (provider name, phone, fax, tax ID, NPI, address, specialty, contact name; facility name and tax ID)
- Completion and legibility: All required fields must be completed and legible
Clinical documentation may be requested at the health plan's discretion
Additional policy applicability
For specified organ transplants, Priority Health's medical policy must also be met:
Transplants requiring adherence to medical policy #91272
- Liver transplant: Priority Health criteria must be met in addition to transplanting institution's selection criteria (see Transplantation of Solid Organs medical policy #91272).
- Islet Cell transplant: Priority Health criteria must be met in addition to transplanting institution's selection criteria (see medical policy #91272).
- Intestinal transplant: Priority Health criteria must be met in addition to transplanting institution's selection criteria (see medical policy #91272).
- Small Bowel / Liver transplant: Priority Health criteria must be met in addition to transplanting institution's selection criteria (see medical policy #91272).
- Multivisceral transplant: Multivisceral (small bowel / liver and/or stomach, pancreas, colon): Priority Health criteria must be met in addition to transplanting institution's selection criteria (see medical policy #91272).
Required coding on request
| unspecified | Form requests 'Procedure code(s) - CPT' to be provided; no specific CPT codes listed in form. |
| unspecified | Form requests 'Diagnosis code(s)' to be provided; no specific ICD-10 codes listed in form. |
What providers must do
Prior authorization submission
Providers must complete and submit this prior authorization form with all required fields legible; Priority Health may request clinical documentation at its discretion for review.
Transplant institution selection criteria
For certain transplants (liver, islet cell, intestinal, small bowel/liver, multivisceral), providers must meet Priority Health's Transplantation of Solid Organs medical policy #91272 in addition to the transplanting institution's selection criteria.
Provide CPT and diagnosis codes
Request must include primary procedure description and CPT procedure code(s) and diagnosis code(s); absence may delay or prevent prior authorization.
- Absence of CPT procedure code(s) may delay or prevent authorization
- Absence of diagnosis code(s) may delay or prevent authorization
Background & definitions
The form collects member demographics (last name, first name, Priority Health ID#, date of birth), transplant evaluation and listing details (HLA typing, listing start date, date of service, primary diagnosis description, diagnosis code(s), and organ(s) requested), admission and procedure information (date of admission, date of transplant, primary procedure description, procedure code(s) - CPT), and requesting provider and facility identifiers (provider and facility names, tax IDs, NPI, addresses, phone/fax, specialty, and contact name).
Providers must complete and submit this prior authorization form with all required fields legible; Priority Health may request clinical documentation at its discretion for review. The form is used to request review/authorization for solid organ transplants and references medical policy #91272 for additional clinical criteria where applicable.
Revision history
Current status: PRIOR AUTHORIZATION FORM in use (CURRENT). Providers must complete and submit the solid organ transplant prior authorization form with all required fields legible; clinical documentation may be requested at the plan's discretion. The form collects member identifying information, transplant evaluation and listing details, transplant type, admission and procedure dates, and provider/facility identifiers, and requires CPT procedure code(s) and diagnosis code(s) to be provided. For liver, islet cell, intestinal, small bowel/liver, and multivisceral transplants, Priority Health's Transplantation of Solid Organs medical policy #91272 must also be met in addition to the transplanting institution's selection criteria. No dated revision events provided.
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