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December 2016
Basic organ, bone marrow transplant donor services covered in 2017
Starting Jan.1, 2017, Blue Cross Blue Shield of Michigan will cover living donor-related services under the recipient’s medical policy when the donor isn't a listed member.
- Only bill the recipient’s medical policy for living donors who are donating to a member on the policy.
- These changes don't apply to self-donations or cadaveric donations.
- This change only applies to Blue Cross basic organ transplants (bone marrow, kidney, cornea and skin).
This change doesn’t apply to members enrolled in the following groups:
- UAW Retiree Medical Benefits Trust™
- General Motors
- Ford hourly
- Fiat Chrysler Automobiles
Basic organ transplant, living donor billing guidelines
When a Blue Cross member is the recipient of a basic organ:
- Continue to follow the usual billing guidelines.
- Submit the claim using the recipient’s name and member ID number with the applicable recipient procedure and diagnosis codes.
When a member is the donor of a basic organ:
- Submit the claim using the recipient’s name and the recipient’s member ID number.
- Use the applicable donor procedure and diagnosis codes.
When you have a non-plan, member-donor claim:
- Use the donor diagnosis codes in the Z52- code section in the ICD-10-CM code set.
- List the Z52- diagnosis codes as a principal diagnosis code.
- Providers may also submit an attachment that indicates the patient is a donor, but it isn't required.
If the donor and the recipient are family members with coverage under the same policy:
- Submit the claims using the respective donor and recipient names.
- Use the applicable procedure and diagnosis codes for recipient and donor.
This billing requirement is for basic organ transplants only and doesn't apply to specified organ transplants.
Continue following the usual billing processes for all other organ transplants.
This requirement doesn't change any group benefits, it places the medical necessity and financial responsibility with the recipient. The donor won’t be billed. Donor coverage for complications is included in the post-operative care period.
Payment of donor charges under recipient coverage applies to basic organ transplants, bone marrow, kidney, cornea and skin. Starting Jan. 1, 2017, we’ll charge donor services to the Blue Cross recipient’s medical policy up to the contract limits. |
If: |
Medical necessity rests on the recipient, then: |
Recipient and donor are both Blue Cross-eligible members |
- Submit claims under recipient’s contract with appropriate donor, recipient procedure and diagnosis codes.
- We'll provide coverage for the recipient and donor.
- The donor isn't charged.
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Recipient has Blue Cross coverage, and donor has other insurance |
Donor has no coverage, and the recipient has Blue Cross coverage |
Donor has Blue Cross coverage, and recipient has other insurance |
- Submit claims under recipient’s contract with appropriate donor, recipient procedure and diagnosis codes.
- The recipient’s plan is billed for the donor charges.
- If the Blue Cross member donor claim is rejected by the other carrier because it's not a benefit, then the donor services are charged against their Blue Cross policy.
- Donor is responsible for their cost share.
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Note: If the donor and the recipient are family members with coverage under the same policy, submit the claims using the respective donor and recipient name. |
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