Prior Authorization for Transplant Services
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Governs prior authorization requirements for organ transplant services for South Carolina Healthy Connections Medicaid members; affects providers performing or arranging transplants and related billing/authorization processes.
No material clinical or coverage changes in this revision.
Organ Transplant Coverage Requirements
Prior Authorization and Responsibility
Prior authorization is required for all organ transplant services for Healthy Connections Medicaid members. KePRO (the agency's QIO) approvals are accepted for out-of‑state treatment when applicable; managed care organizations retain responsibility except as noted below.
ALL of the following
- Prior authorization must be obtained for all organ transplant services rendered to South Carolina Healthy Connections Medicaid members.
- Providers must continue to contact the agency’s QIO, Keystone Peer Review Organization (KePRO), for prior authorization before rendering transplant services.
- Effective Jan. 1, 2022, SCDHHS will accept prior approval of an organ transplant by KePRO as approval for a Healthy Connections Medicaid member to be treated out of state, when applicable.
- Transplant requests should include the Transplant Prior Authorization Request Form and a letter from the attending physician describing the type of transplant, the patient’s current medical status, course of treatment, and the name of the receiving center.
- If KePRO approves the request, it will issue an approval letter with an authorization number that must be included on all claims for transplants and related services.
- For members enrolled in a managed care plan, the managed care organization remains responsible for transplants except for services rendered 72 hours prior to inpatient hospital admission through discharge.
Provider Responsibilities and Authorization Process
Prior authorization required from KePRO (QIO)
Providers must obtain prior authorization from the agency's QIO, Keystone Peer Review Organization (KePRO), before rendering any organ transplant services for Healthy Connections Medicaid members. KePRO approval will be accepted as approval for out-of-state treatment when applicable.
Managed care organization responsibility exception
For members enrolled in a managed care plan, the managed care organization is responsible for transplant authorizations except for services rendered 72 hours prior to inpatient hospital admission through discharge, which remain under the agency/QIO responsibility.
Required documentation for transplant prior authorization
Transplant prior authorization requests must include the Transplant Prior Authorization Request Form and an attending physician letter describing the type of transplant needed, the patient's current medical status, the course of treatment, and the name of the receiving center.
Include KePRO authorization number on all transplant claims
If KePRO approves the request it will issue an approval letter containing an authorization number; that authorization number must be included on all claims for transplants and related services.
- Providers must include the KePRO-issued authorization number on every claim for transplant and related services.
- Providers may contact KePRO with questions at (855) 326-5219.
Key Definitions
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