Kidney-only transplants to require prior authorization, starting Jan. 1

For dates of service on or after Jan. 1, 2024, hospital transplant financial coordinators must submit prior authorization requests for kidney-only transplants through the e-referral system for:

• Blue Cross Blue Shield of Michigan fully insured group and individual commercial members
• Blue Care Network fully insured group and individual commercial members
• All BCN Advantage℠ members

As with other transplants that already require prior authorization — including simultaneous pancreas-kidney, or SPK — it’s a two-step process in the e-referral system:

1. Submit an outpatient prior authorization request that includes:
• Procedure codes *50360 and *50365
• The facility
• For commercial members, enter a Blue Distinction^® Center for Transplants.
• For BCN Advantage members, enter a facility that’s accredited by the Centers for Medicare & Medicaid Services for kidney transplants.
• The completed questionnaire — The questionnaire automatically opens in the e-referral system for you to fill out.
• Clinical information — Include the history and physical, the letter of intent and clinical documentation to support the need for the transplant.

The request will pend for clinical review. In addition, the request will require medical director review if the facility isn’t a Blue Distinction Center for Transplants (for commercial members), the facility isn’t accredited by CMS for kidney transplants (for BCN Advantage members) or the member doesn’t meet medical policy criteria. 

If the authorization is approved, it will be valid for one year.

2. When a kidney becomes available, submit a prior authorization request for the inpatient stay. Include the outpatient authorization number for the transplant procedure codes in the Case Communication field. This will enable us to issue an approval quickly as it makes the connection between the inpatient request and the already-approved outpatient authorization.

You’ll be able to start submitting requests through the e-referral system for kidney-only transplants on Jan. 1, 2024.

We’ll update the e-referral User Guide for kidney-only transplants before Jan. 1. The pertinent information will be in “Section IV: Referrals and Authorizations,” in the subsection titled “5. Submit an Outpatient Authorization.” (The e-referral User Guide also includes information about submitting a re-authorization request, if the authorization obtained through Step 1, mentioned above, expires before a kidney becomes available.)

Notes:

• For more information about Blue Distinction Centers, see the Blue Distinction Centers webpage on our ereferrals.bcbsm.com website.
• If the e-referral system isn’t available or isn’t performing as expected, see the document titled e-referral system maintenance times and what to do.
• This prior authorization requirement for kidney-only transplants is already in place for the Blue Cross and Blue Shield Federal Employee Program^® members.