HMO Provider Manual 07/01/2023: Section 7 Medical Management Programs & Policies

The Transplant team’s review of services includes solid organ (kidney, heart, lung, liver, pancreas, intestinal, multi-visceral, and combination organ) transplants, bone marrow and stem cell (autologous and allogeneic) transplants, chimeric antigen receptor (CAR)-T, and gene replacement. 

All delegated medical groups must notify the Anthem Blue Cross’ (Anthem) Centers of Medical Excellence (CME) Transplant and Special Therapy department when a member is referred for evaluation. The department requires an authorization for transplant and admitted for transplant within one business day. Send referrals to Anthem at the address or phone number provided in Section 2, Quick References, under CME Transplant and Special Therapy department. Select this link for contact information. 

Transplant medical necessity review is the responsibility of Anthem’s Transplant team. This includes initial evaluation, prior authorization, inpatient concurrent review, and discharge planning. The initial evaluation involves Anthem’s Transplant team reviewing member benefits and verification that the requested facility meets network requirements before consultation with the facility Transplant team.   

Transplant, CAR-T, and gene replacement therapy global period is outlined on the contract attachment provided upon approval of the service. During this global period, the Transplant team will review the transplant services for the member. Post global period, the UM review is the responsibility of the medical group.   

Financial responsibility for transplant and non-transplant related medically necessary covered services remain as described in the Division of Financial Responsibilities matrix in the Provider Agreement. 

Post-transplant, Anthem’s Transplant case manager works in conjunction with the member’s transplant team, PCP, and other clinicians to complete an assessment of the member’s healthcare needs, develop, implement, and monitor a care plan, coordinate services, and re-evaluate the care plan for the member. All care providers must obtain prior authorization for transplant evaluations and transplant surgery, regardless of financial risk. Transplant evaluations and surgery must be performed at one of Anthem’s Centers of Excellence or facilities approved by Anthem’s Transplant medical directors.