New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 52 - HOSPITAL SERVICES MANUAL
Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES
Section 10:52-2.9 - Organ procurement and transplantation services

Universal Citation: NJ Admin Code 10:52-2.9

Current through Register Vol. 56, No. 18, September 16, 2024

(a) The Division shall reimburse for medically necessary transplantation services, including organ procurement, except those transplants categorized as experimental. (See (d) below for further information on organ procurement and transplantation.)

1. Claims for transplant services and organ procurement services rendered to or items dispensed or furnished to an organ donor shall be submitted using the Health Benefits Identification Number of the Medicaid/NJ FamilyCare beneficiary who is receiving the transplant.

2. The organ donor's claim will be paid by the Medicaid/NJ FamilyCare program whether the claim is from the same hospital where the transplant service was provided to the Medicaid/NJ FamilyCare patient or from a different hospital.

(b) Federal organ procurement service requirements are listed in the Social Security Act, Section 1138 as amended by Section 9318(a) of the Omnibus Budget Reconciliation Act of 1986 (42 U.S.C. § 1320) .

1. Organ procurement services, with the exception of bone marrow transplant and cornea procurement services, are covered only when the Organ Procurement Organization (OPO) meets the requirements as outlined in the Section 1138 of the Social Security Act (42 U.S.C. § 1320(b)-8 Note) and when the OPO is designated and certified by the Secretary of the Department of Health and Senior Services and Human Services as the OPO for that geographical area in which the hospital is located.

(c) The covered organ transplantation procedures shall be performed in an organ transplant center approved or certified by a nationally recognized certifying or approving body, or one designated by the Federal government. In the absence of such a certification or approval of a nationally recognized body, the approval or certification, whichever applies, shall have been obtained from the appropriate body so charged in the State in which the organ transplant center is located.

(d) The candidate for transplantation shall have been accepted for the procedure by the transplant center. All out-of-State hospitalizations for transplantations shall require prior authorization from the Medical Assistance Customer Center (MACC) serving the beneficiary's county of residence.

(e) Organ transplantations shall be medically necessary. Transplantations, with the exception of cornea transplantations, shall be performed only to avert a potentially life-threatening situation for the patient.

1. If all factors pertinent to decision-making concerning the site of performance of a transplant procedure are essentially equal, preference shall be given to a New Jersey transplant center. However, Medicaid policy of equitable access also applies (see 42 CFR 431.52(c)) .

(f) For organ transplants for Medicaid/NJ FamilyCare beneficiaries enrolled with a managed care organization, the managed care organization shall be responsible for all costs, except for the costs of the hospital, for an individual placed on a transplant list while in the Medicaid/NJ FamilyCare fee-for-service program prior to enrollment in a managed care organization under contract with the Department of Human Services.

Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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