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California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more
California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more

23-220 Follow Organ Transplant Referral and Authorization Process to Avoid Delays

Date: 03/10/23

Transplant centers submit requests for authorization to the Centene Centralized Transplant Unit (CTU)

Physicians and other providers must follow the below organ transplant referral and authorization processes for each specified line of business.

Medi-Cal organ transplant process for members under age 21

All transplant services for California Health & Wellness Plan (CHWP) Medi-Cal members under age 21 are coordinated through California Children's Services (CCS). CHWP is not responsible for payments related to any transplant or post-transplant care for Medi-Cal members under age 21, as these services are carved out to the CCS program.

Medi-Cal members under age 21 with CCS-eligible conditions who require transplants must be referred to CCS. CHWP assists to ensure timely referral to the CCS program.

A primary care physician (PCP) or specialist who identifies a member as a potential candidate for transplant services must submit a referral to the appropriate CCS program office and request prior authorization for a pre-transplant evaluation at a CCS-approved facility. If the CCS program office deems the member to be a potential candidate, the transplant physician must submit a Service Authorization Request (SAR) in a timely manner to the appropriate CCS program office and coordinate services with the CCS case manager. 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.

Medi-Cal organ transplants for members ages 21 and over

All organ transplants are covered under the CHWP Medi-Cal contract. There is no independent practice association (IPA) delegation for Medi-Cal transplant services.

CHWP covers the cost of medically necessary, non-experimental and non-investigative organ and stem cell transplants at Medi-Cal approved, CHWP Transplant Performance Centers (Centers). Service requests are evaluated on a case-by-case basis and must be prior authorized through CHWP.

Referral process for solid organ transplant and bone marrow transplant for members ages 21 and over

A PCP, specialist or IPA who identifies a member as a potential candidate for transplant services must provide applicable medical records to a Medi-Cal approved, CHWP Transplant Performance Center (Center) for transplant evaluation.

The Center must submit a prior authorization request for the evaluation to the Centene Centralized Transplant Unit (CTU) through the provider portal, or via fax directly to the CTU at 833-769-1141. On receipt of a request for a transplant, the CTU contacts the Center to request any necessary medical records to complete the clinical review. Once complete medical records are received, a review is performed to establish medical necessity. If approved, the Center is notified and provided an authorization number for the evaluation.

Once a member has completed an evaluation, and is approved by the Center for transplant, the Center must submit a prior authorization request for listing to the Centene CTU through the provider portal, or via fax directly to the CTU at 833-769-1141. On receipt of a request for a listing, the CTU contacts the Center or other provider to request any necessary medical records to complete the clinical review. Once complete medical records are received, a review is performed to establish medical necessity. If approved, the Center is notified and provided an authorization number.

Submit CAR-T cell therapy, corneal transplant, tissue transplant, pancreatic islet cell auto-transplant after pancreatectomy, or parathyroid auto-transplant after thyroidectomy requests directly to CHWP.

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.

 

This Information applies to Physicians, Independent Practice Associations (IPAs), Hospitals, and Ancillary Providers.