Transplant Provider Requirements

Transplant Provider Requirements Providers of transplant services must: A. Complete the requirements for participation in the Mississippi Medicaid program. B. Meet the following facility criteria: 1. Solid organ transplant procedures must be performed in a facility which meets the Centers for Medicare and Medicaid Services (CMS) requirements for Conditions of Participation approved as a transplant facility unless otherwise authorized by the Division of Medicaid, and 2. Bone marrow and stem cell transplant procedures must be performed in a facility accredited by a CMS-deemed national accreditation organization. C. Obtain prior authorization from a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity for the inpatient hospital admission and for outpatient services, if required, for the transplant procedure as soon as it is determined that the beneficiary may be a potential candidate for the transplant. 1. The prior authorization request must include, but is not limited to the following: a) A description of the medical condition which necessitates the transplantation, b) Diagnostic confirmation by clinical laboratory studies of the underlying pathological process, c) A history of other treatments which have been tried and treatments which have been considered and ruled out, including an explanation as to why the treatment was ruled out, d) Comprehensive assessments: 1) Examination, evaluation and recommendations completed by a board-certified or board-eligible specialist in a field directly related to the beneficiary's condition which necessitates the transplantation, 2) Psycho-social evaluation including a comprehensive history of substance abuse and compliance with any medical treatment of: (a) The beneficiary, and (b) The parents or guardian/legal representative if the beneficiary is less than eighteen (18) years of age, e) Psychiatric evaluation of the beneficiary if the beneficiary has a history of mental illness, f) Infectious disease evaluation of a beneficiary with a recent or current suspected infectious episode, g) Evaluation of a beneficiary diagnosed with cancer that includes staging of the cancer, laboratory tests, and imaging studies, and h) Any other medical evidence needed to evaluate possible contraindications for the type of transplantation being considered. 2. Prior authorization is not required for transplants when the beneficiary has Medicare coverage. 3. Prior authorization is required for transplants when the beneficiary has third party coverage and the hospital intends to bill Medicaid for any transplant related hospital charges. D. Ensure that the transplant procedure is performed at the facility requesting prior authorization for the transplant procedure. E. Submit documentation for a concurrent review for beneficiaries not enrolled in a Coordinated Care Organization (CCO) to a UM/QIO, the Division of Medicaid, or designated entity if a beneficiary’s length of stay exceeds nineteen (19) days. F. Provide the appropriate medical records, progress or outcome reports as requested by a UM/QIO, the Division of Medicaid, or designated entity.