CurrentUCarePolicy N/A

Transplant services prior authorization

This form governs prior authorization, listing, and notification requirements for organ and hematopoietic stem cell transplant services for UCare members and must be completed by providers submitting transplant-related requests.

Policy Summary

PayerUCare

PolicyTransplant services prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form with supporting clinical documentation via fax or secure e-mail to demonstrate medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3authorization request types on form

2submission methods listed

ICD-10diagnosis code system

multipleorgan/HSCT types

Coverage Requirements and Criteria

Administrative coverage requirements

Covered when provider submits required authorization type and supporting documentation:

Submission requirements: Provider must complete and submit the transplant services prior authorization form and supporting clinical documentation via fax or secure e-mail

Incomplete, illegible, or inaccurate forms may be returned; failure to provide required documentation may result in denial of the request

Authorization types: Provider must select the appropriate authorization type on the form: Consult/Evaluation, Listing, or Transplant Procedure

For Transplant Procedure and Listing, notification is required at time of transplant procedure

Submission methods: Submit form and clinical documentation by fax to 612-884-2499 or 1-866-610-7215 or via UCare secure e-mail

Policy Summary

PayerUCare

PolicyTransplant services prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form with supporting clinical documentation via fax or secure e-mail to demonstrate medical necessity.

SourceLink

On This Page

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The transplant prior authorization form includes facility designation checkboxes to indicate whether the transplant will occur at a CONTRACTED or NON-CONTRACTED facility. The form does not list any clinical exclusions tied to facility selection; it is intended to capture facility identification and contractual status only.

Procedure and Diagnosis Codes

Procedure CPT Codes (provider-supplied)CPT

CPT	CPT Code(s): (form requests provider-entered CPT codes for each organ type)

Diagnosis CodesICD-10

ICD-10

ICD-10 Codes: (form requests diagnosis codes)

Provider Submission, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization is required for transplant consult/evaluation and for transplant listing. Notification is required at the time of the transplant procedure.

Prior Authorization required for transplant consult/evaluation
Prior Authorization required for transplant listing
Notification required at time of transplant procedure

Note

Submission Methods

Fax the completed Transplant Services Prior Authorization form and all relevant clinical documentation to UCare. You may also submit via UCare's secure e-mail.

Fax: 612-884-2499 or 1-866-610-7215
E‑Mail: HCM_Fax@ucare.org (UCare Secure E-mail Site)

Documentation Required

Submission and Documentation

Submit a completed Transplant Services Prior Authorization form with supporting clinical documentation to demonstrate medical necessity. Incomplete, illegible, or inaccurate forms will be returned. Failure to provide required documentation may result in denial of the request.

Include completed prior authorization form
Include supporting clinical documentation to support medical necessity
Incomplete, illegible, or inaccurate forms will be returned — may result in denial

Denial Risk

Form Completeness and Required Information

On the prior authorization form indicate the type of request and relevant dates; for transplant procedures, notify UCare at the time of the transplant. Also indicate whether the member is currently inpatient at the transplant facility.

Check the appropriate request type: Consult/Evaluation, Listing, Transplant Procedure and provide dates
Indicate member inpatient status at transplant facility (Yes/No)
Notify UCare at time of transplant procedure

Form Purpose and Information Collected

The form collects standard transplant request information including patient and provider identifiers, the transplant practitioner and transplant coordinator contact details, facility information, and the specific organ or hematopoietic stem cell (HSCT) type. Providers are asked to specify the transplant type (for example single or bilateral for lungs and HSCT subtypes) and to provide associated procedure and diagnosis codes to support authorization, listing, or procedure notification.

Transplant Type Definitions

HSCT and Organ Types

Hematopoietic Stem Cell (HSCT) subtypes listed on formAuto; Allo-related; Allo-unrelated; Allo-unspecified; Umbilical cord blood

Organ/Transplant types enumeratedHeart; Lung (single or bilateral); Liver; Pancreas; Small Bowel; Small Bowel/Liver; Multivisceral; Hematopoietic Stem Cell; Other

Provider-entered CPT codes requiredForm requests CPT Code(s) and Procedure Date for each selected organ/HSCT type

Other transplant entry‘Other’ option available with space to specify type plus CPT and procedure date

Organ and Transplant Type Selection

Organ/transplant types

Provider must specify organ/transplant type and associated procedure codes and dates on the form for authorization, listing, or procedure notification:

Organ/HSCT selection: Form lists Heart, Lung (single or bilateral), Liver, Pancreas, Small Bowel, Small Bowel/Liver, Multivisceral, Hematopoietic Stem Cell (with subtype checkboxes: Auto, Allo-related, Allo-unrelated, Allo-unspecified, Umbilical cord blood), and Other

Provider must supply CPT code(s) and procedure date for the selected organ type on the form

Inpatient status: When completing the form, indicate whether the member is currently inpatient at the transplant facility (Yes/No)

This field is required for listing/evaluation entries as shown on the form

Contraindications

No contraindications are specified on the transplant prior authorization form.

Evaluation and Listing Requirements

Prior Authorization

Authorization required for evaluation and listing; mark candidacy/status

Prior authorization is required for both the transplant consult/evaluation and for transplant listing; when completing the request, providers must indicate whether the member is a candidate and note inpatient status on the form.

Check the appropriate box for Consult/Evaluation, Listing, or Transplant Procedure on the prior authorization form
Indicate if the member is currently inpatient at the transplant facility

Facility and Center Information

Note

Indicate facility contract status

The form includes a CONTRACTED checkbox for the facility; no specific accreditation or volume requirements are stated on the form.

Select CONTRACTED or NON-CONTRACTED as appropriate on the facility section of the form

Notification and Post-Transplant Reporting

Transplant Procedure Notification

Notification requirementNotification is required at time of transplant procedure — submit the transplant procedure notification on the form

Authorization types on formForm includes checkboxes for Consult/Evaluation, Listing, and Transplant Procedure with spaces for dates

Inpatient status indicationForm asks whether the member is currently inpatient at the transplant facility (Yes/No)

Submission methodsFax to 612-884-2499 or 1-866-610-7215, or securely e-mail to HCM_Fax@ucare.org