New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 54 - PHYSICIAN SERVICES
Subchapter 5 - POLICIES AND PROCEDURES FOR PROVISION OF SERVICES PRESCRIBED OR RENDERED BY A PHYSICIAN
Section 10:54-5.32 - Organ procurement and transplantation services

Universal Citation: NJ Admin Code 10:54-5.32

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

(a) The Division covers services rendered and items dispensed or furnished in connection with organ procurement and transplantation services of kidney, heart, heart-lung, liver, bone marrow, cornea and other selected medically necessary organ transplants except those transplants categorized as experimental. (See (d) below for further information on organ procurement and transplantation.)

1. Payment for organ procurement and transplant services rendered to or items dispensed or furnished a donor will be considered a charge on behalf of the Medicaid beneficiary who is the transplant beneficiary.

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

1. Procurement services, with the exception of bone marrow transplant and cornea procurement services, shall be covered only when the Organ Procurement Organization (OPO) meets the requirements of 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 Human Services as the OPO for that geographical area in which the hospital is located.

(c) The covered organ transplantation procedures shall also 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 this nationally recognized body, the approval or certification, whichever applies, shall be 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. Such acceptance shall precede a request for prior authorization from the medical staff in the Division's Office of Utilization Management, if applicable. All out-of-State hospitalizations for transplantations require prior authorization from the MACC serving the beneficiary's county of residence (see 10:49-6.2) . Prior authorization shall be required for hospitalizations for organ procurement and transplantation for Medicaid/NJ FamilyCare beneficiaries for anatomical sites not explicitly listed in (a) above.

(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/NJ FamilyCare policy of equitable access also applies (see 42 CFR 431.52(c)) .

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