Prior Authorization for Transplant Services

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Effective Jan. 1, 2022, the South Carolina Department of Health and Human Services (SCDHHS) will accept prior approval of an organ transplant by the agency’s quality improvement organization (QIO) as approval for a Healthy Connections Medicaid member to be treated out of state, if applicable. The agency’s QIO is Keystone Peer Review Organization (KePRO). Providers must continue to contact KePRO for prior authorization before rendering transplant services. This policy and its requirements are included in section 7 of SCDHHS’ Hospital Services provider manual.

Transplant requests should include the Transplant Prior Authorization Request Form, a letter from the attending physician that describes the type of transplant needed, the patient’s current medical status, the course of treatment, and the name of the center to which the patient is being referred. The QIO will review the request and, if approved, issue an approval letter with an authorization number that will be used by the hospital and physicians. For members enrolled in a managed care plan, transplants remain the responsibility of the managed care organization with the exception of services rendered 72 hours prior to inpatient hospital admission through discharge.

SCDHHS requires providers to obtain prior authorization for all organ transplant services rendered to South Carolina Healthy Connections Medicaid members. This policy and its requirements are included in section 7 of SCDHHS’ Hospital Services provider manual.

All claims for transplants and related services must be submitted with the authorization number provided by KePRO. Providers may direct questions regarding this authorization process to KePRO at (855) 326-5219.

Providers with other questions regarding this bulletin should contact the SCDHHS Provider Service Center at (888) 289-0709. The Provider Service Center’s hours of operations are 7:30 a.m.-5 p.m. Monday-Thursday and 8:30 a.m.-5 p.m. Friday.

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