CurrentSelectHealthPolicy # 86

Travel allowance for organ transplant services

Defines SelectHealth coverage for travel allowances (transportation, lodging, food) associated with preauthorized organ transplant services for Commercial and CHIP plans, with Medicare and Medicaid subject to CMS/State determinations. Specifies covered organ transplants and per-diem/allotment limits and applicability notes.

Policy Summary

PayerSelectHealth

PolicyTravel allowance for organ transplant services

Policy CodePolicy Policy # 86

Change TypeNon-material revision (6/27/24)

Effective Date12/28/20

Next Review Date

Key ActionOrgan transplant services must be preauthorized to qualify for the travel allowance.

SourceLink

POLICY UPDATE CHANGES

Revision date listed as 6/27/24; no material clinical policy statement changes indicated.

9Covered Organ Types Listed

$200/dayPer-diem Allowance

50Maximum Days Covered

Coverage Summary

Defines Select Health coverage for a travel allowance (transportation, lodging, and food) associated with preauthorized organ transplant services for Commercial and CHIP plans. Coverage is covered with criteria (Policy # 86) and requires preauthorization and plan enrollment rules. The policy specifies a per-diem allowance of $200 per day with a maximum of 50 days. For Medicare Advantage and Medicaid, coverage follows CMS and State determinations respectively; if no government policy is available, InterQual or Select Health Commercial criteria apply.

Medical Necessity Criteria

Commercial Plan and CHIP Travel Allowance Criteria

Covered when ALL of the following are met:

ALL of the following

Preauthorization required: Organ transplant services have been preauthorized (preauthorization required).
Eligible plans: Member is enrolled in Select Health Commercial plan or Select Health Community Care CHIP (applies currently to Nevada Small Employer and Individual plans).
Covered transplant types: Transplant procedure is one of the covered organ transplants listed below (bone marrow; combined heart–lung; combined pancreas–kidney; heart; kidney (except to the extent covered by any government program); liver; pancreas after kidney; single or double lung; small bowel).
Benefit limitations may apply per plan; member's individual benefit plan in effect at time of service determines actual coverage.

Medicare (Select Health Advantage) and Medicaid (Select Health Community Care) Guidance

Coverage follows government determinations when available:

ALL of the following

Medicare determinations: For Medicare Advantage (Select Health Advantage), coverage is determined by the Centers for Medicare & Medicaid Services (CMS); if CMS has not adopted a determination and InterQual criteria are not available, the Select Health Commercial policy applies.
Medicaid determinations: For Medicaid (Select Health Community Care), coverage is determined by the State of Utah Medicaid program; if Utah Medicaid has no published coverage position and InterQual criteria are not available, the Select Health Commercial criteria apply.

Provider Actions

Prior Authorization

Preauthorization required

Organ transplant services must be preauthorized to qualify for the travel allowance.

Documentation Required

Benefit determination by plan

Providers must verify member eligibility and benefit limitations per the member's individual benefit plan at time of service; benefits may vary by plan and state.

Background

Select Health offers a travel allowance for transportation, lodging, and food costs associated with organ transplant services when those transplant services have been preauthorized. Medicare Advantage coverage is determined by CMS and Medicaid coverage is determined by the State (Utah); if a government determination is not available, InterQual or Select Health Commercial criteria apply as the fallback.

Travel allowance: An allotment for transportation, lodging, and food costs associated with preauthorized organ transplant services.