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21-780 Transplant Benefit for Medi-Cal Members

Date: 10/27/21

Submit major organ transplant and corneal transplant requests to California Health & Wellness Plan

Per All Plan Letter 21-0151, as part of the California Advancing and Innovating Medi-Cal (CalAIM) initiative to standardize managed care plan benefits, all Medi-Cal managed care health plans are required to cover the major organ transplant (MOT) benefit, including related services such as organ procurement and living donor care.

Effective January 1, 2022, California Health & Wellness Plan (CHWP) will cover and manage MOT, including related services, for adult Medi-Cal members.

For Medi-Cal members under age 21, pediatric transplant services remain a carve-out to California Children's Services (CCS). Transplant service requests must be submitted to the appropriate CCS office. If the CCS program determines that the member is not eligible for the CCS program, but the transplant service is medically necessary, CHWP will be responsible for authorizing the transplant service, as appropriate.

Delegated independent practice associations

Beginning January 1, 2022, independent practice associations (IPAs) are required to submit requests to CHWP for all MOT-related care and corneal transplants for Medi-Cal members ages 21 and over. There will be no IPA delegation for Medi-Cal transplants.

Covered benefits

For adult members ages 21 and over, CHWP covers the professional and institutional costs of medically necessary MOT and corneal transplants. MOT and corneal transplants require prior authorization and must be performed at a Medi-Cal-approved Center of Excellence (COE) transplant program.

Prior authorization

A primary care physician (PCP), specialist, IPA or facility who identifies a member as a potential candidate for transplant services must submit a request for a transplant evaluation to CHWP for prior authorization.

Services requiring prior authorization include, but are not limited to:

  • Transplant evaluation.
  • Transplant consult visits.
  • Donor search.
  • Transplant procedure.

Providers must submit clinically relevant information for medical necessity review with the prior authorization request. Fax authorization requests to the Transplant Team at 833-769-1140.

Additional information

Relevant sections of the provider operations manuals have been revised to reflect the information contained in this update as applicable. The provider operations manual is available in the Provider Resources section of the provider website.

Providers are encouraged to access CHWP’s provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CHWP at 877-658-0305.