Transplants Benefits. Transplants which are non-experimental or non-investigational are a Covered Benefit. Covered transplants must be ordered by the Member’s PCP and Participating Specialist Physician and pre-authorized by HMO's Medical Director. The transplant must be performed at Hospitals specifically approved and designated by HMO to perform these procedures. A transplant is non-experimental and non- investigational hereunder when HMO has determined, in its sole discretion, that the Medical Community has generally accepted the procedure as appropriate treatment for the specific condition of the Member. Coverage for a transplant where a Member is the recipient includes coverage for the medical and surgical expenses of a live donor, to the extent these services are not covered by another plan or program.
Transplants Benefits. Once it has been determined that a Member may require a Transplant, the Member or the Member’s Physician must call the HMO precertification department to discuss coordination of the Transplant process. Non-experimental or non-investigational Transplants coordinated by HMO and performed at an Institute of Excellence, (IOE), are Covered Benefits. The IOE facility must be specifically approved and designated by HMO to perform the Transplant required by the Member. Covered Benefits include the following when provided by an IOE. • Inpatient and outpatient expenses directly related to a Transplant Occurrence. • Charges made by a Physician or Transplant team. • Compatibility testing of prospective organ donors who are immediate family members. For the purpose of this coverage, an “immediate” family member is defined as a first-degree biological relative. These are your: biological parent, sibling or child. • Charges for activating the donor search process with national registries. • Charges made by a Hospital or outpatient facility and/or Physician for the medical and surgical expenses of a live donor, but only to the extent not covered by another plan or program. • Related supplies and services provided by the IOE facility during the Transplant Occurrence process. These services and supplies may include: physical, speech and occupational therapy; bio- medicals and immunosuppressants; Home Health Services and home infusion services. Any Copayments or Coinsurance associated with Transplants are set forth in the Schedule of Benefits. Copayments or Coinsurance apply per Transplant Occurrence. One Transplant Occurrence includes the following four phases of Transplant care:
Transplants Benefits. Once it has been determined that a Member may require a Transplant, the Member or the Member’s Physician must call the HMO precertification department to discuss coordination of the Transplant process. Non-experimental or non-investigational Transplants coordinated by HMO and performed at an Institute of Excellence, (IOE), are Covered Benefits. The IOE facility must be specifically approved and designated by HMO to perform the Transplant required by the Member. Covered Benefits include the following when provided by an IOE. • Inpatient and outpatient expenses directly related to a Transplant Occurrence. • Charges made by a Physician or Transplant team. • Compatibility testing of prospective organ donors who are immediate family members. For the purpose of this coverage, an “immediate” family member is defined as a first-degree biological relative. These are your: biological parent, sibling or child. • Charges for activating the donor search process with national registries. • Charges made by a Hospital or outpatient facility and/or Physician for the medical and surgical expenses of a live donor, but only to the extent not covered by another plan or program. • Related supplies and services provided by the IOE facility during the Transplant Occurrence process. These services and supplies may include: physical, speech and occupational therapy; bio- medicals and immunosuppressants; Home Health Services and home infusion services. One Transplant Occurrence includes the following four phases of Transplant care:
Transplants Benefits. Covered transplants must be ordered by the Member’s PCP and Participating Specialist Physician and pre-authorized by HMO's Medical Director or Designee. The transplant must be performed at Hospitals specifically approved and designated by HMO to perform these procedures. Coverage for a transplant where a Member is the recipient includes coverage for the medical and surgical expenses of a live donor, to the extent these services are not covered by another plan or program.
