Transplants Step 1 of 4 25% Member Information Enter Member Id and Date of Birth to validate Member before proceeding with the form. Member's ID#* Member's DOB* MM slash DD slash YYYY Name* First Last Error Message Referring Provider InformationProvider NPI* 10 digitsProvider Name* Error Message Provider Phone #*Contact Name* Contact Phone #*Contact Fax #*Email address in order to receive confirmation of request receipt* Transplant Facility InformationFacility NPI* 10 digitsFacility Name* Error Message Department Phone #*Department Fax #*Transplant Coordinator InformationName* Email* Phone #*Fax #* Clinical InformationDiagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Transplant institution’s selection criteria has been met*Transplant institution’s selection criteria has been met *YesNoN/A (Consult, Eval, Post-Op)If applicable, previous transplant date and type Transplant InformationStart Date* MM slash DD slash YYYY End Date MM slash DD slash YYYY Date of Transplant MM slash DD slash YYYY If this is related to an existing authorization, please provide the authorization number Requested Service*Requested Service *EvaluationInitial ListingRecert ListingTransplant ProcedurePost-Transplant Follow-UpType of Transplant*Type of Transplant *Allogeneic BMTAutologous BMTCAR-THeartKidneyLiverLung - SingleLung - BilateralPancreasIntestinal/Multi-VisceralUmbilical Cord BloodMulti-Organ - Please SpecifyOther - Please SpecifyPlease Specify* An Approved Pharmacy Authorization for CAR-T is required, please provide the Pharmacy auth #* Setting InformationIMPORTANT NOTE: The authorization for the chosen setting will only cover services done in that setting. If an authorization is also needed for the other setting, then a separate authorization is needed for the other setting. DO NOT submit a single request for both inpatient and outpatient services.Choose Setting of Requested Service*Choose Setting of Requested Service *InpatientOutpatientIs the member currently inpatient at the transplant facility?*Is the member currently inpatient at the transplant facility? *YesNoNOTE: If member does not receive a transplant while inpatient, and continued follow-up for evaluation or listing is required, a new outpatient transplant prior authorization must be requested upon facility discharge.Admit Date* MM slash DD slash YYYY Admit Date MM slash DD slash YYYY Is the requested service being done during this admission?*Is the requested service being done during this admission? *YesNoIs the requested service being done during this admission?Is the requested service being done during this admission?YesNoCPT/HCPC Code(s) (Click + or - at the right to add additional CPT/HCPC Codes)CPT/HCPC CodeUnits Example CPT code: 12345 Example HCPC code: T2031Clinical Trial, Investigational, Experimental Treatment DetailsTransplant services will be administered within context of an investigational, experimental or research protocol/clinical trial?*Transplant services will be administered within context of an investigational, experimental or research protocol/clinical trial? *YesNoClinical Trial Number* Use actual clinical trial number assigned. If there’s an IDE #, please append it to the clinical trial number. Attach copy of protocol(s).Study's Sponsor* Investigational and/or (non-FDA approved) technology, device(s), services or treatments (non- routine care) will be utilized?*Investigational and/or (non-FDA approved) technology, device(s), services or treatments (non- routine care) will be utilized? *YesNoPlease Specify:* Required Information/DocumentationATTENTION: Requests submitted without sufficient information will encounter delayed processing. Consultation/Evaluation All medical & behavioral health diagnoses Progress notes including disease progression & current status (acute/ chronic, remission, etc.) Be sure to include height and weight or BMI MELD/PELD score (Liver only) Initial Listing & Recertification Everything from Consultation/Evaluation section Prior transplant history Test results Behavioral health, social work, psycho-social support network evaluations (initial only) Dental evaluation Multidisciplinary transplant team documentation Attach Clinical Information* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 10. Signature of Treating Physician*Signature Date* Request Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (7 days for Medicaid and D-SNP; 15 days for Commercial ) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 13 MB.Attach only PDF and Word filesSignature of Physician or Licensed Provider*Signature Date* Comments Authorization is not a guarantee of payment CAPTCHA NameThis field is for validation purposes and should be left unchanged.