Physicians/Specialists
Facilities/Hospitals
Publication Date: 
2021-03-12

Effective January 1, 2021, the Blue Cross Blue Shield Association added kidney transplants to their suite of transplant specialties within the Blue Distinction Center (BDC) program. This new program offers our members access to BDCs that offer high-value, high-quality care in a bundled fee arrangement. The following communication provides details for providers on the kidney transplant process.  

 

Transplant Requirements for Providers 

Effective April 1, 2021, prior plan authorization (PPA) will be required for all members in need of kidney transplants. Applicable service codes will be placed on the PPA list. See below for details: 

  • All kidney transplant requests will require review by the Blue Cross and Blue Shield of North Carolina (Blue Cross NC) Transplant Case Management Team, including requests for emergent, elective, pre- or post-service and living or deceased donor kidney transplants. A case manager will perform prior authorization and case management services for the member to ensure benefit and eligibility requirements are met along with medical necessity criteria.    
  • PPA is required for all transplants including those transplants not in the BDC program. 
  • To ensure claims are processed correctly for health systems with a BDC designation, special claim processes conducted by transplant case managers are needed for ALL members. 
  • Members who have been on the transplant list long-term should be identified early and communicated to Blue Cross NC to ensure appropriate benefits and claims are processed without disruption. 

 

Grandfathered Kidney Transplant Claims 

If a member is in the advanced planning stages of kidney transplant services at a non-BDC facility, members can continue with the active course of care to avoid disruption. Please follow the prior authorization process to notify Blue Cross NC and ensure the appropriate exception approval is in place to allow for the proper adjudication of claims.  

 

Impacted Lines of Business  ​

This program applies to all commercial membership, Administrative Services Only (ASO) membership, and State Health Plan (SHP) membership receiving transplants within North Carolina or Out-of-State. Blue Card members receiving services within North Carolina are subject to the prior authorization requirements from their home plan. 

 

Transplant Benefit Verification  

For any member already in your kidney transplant program (BDC or non-BDC) and any future requests for transplant evaluation (BDC or non-BDC), please call the transplant line for benefit verification at 919-765-2924 and fax all requests to 919-765-1553.