OAR 410-124-0006: Transplant Hospital Requirements And Reimbursement

Transplant services shall be reimbursed only when provided in a transplant hospital that meets the Division requirements. (1) Medicare certified transplant facility. (2) Must be an enrolled provider with Oregon Health Authority, Health Systems Division outlined in OAR 410-120-1260. (3) Selection of transplant hospitals by geographic location: If the services are available in the state of Oregon, reimbursement shall not be made to out-of-state transplant hospitals. (4) Out-of-state transplant hospitals shall be considered only if: (a) The type of transplant required is not available in Oregon and/or the type of transplant (for example, liver transplant) is available in Oregon but the Oregon transplant hospital does not provide that type of transplant for all clients or all covered diagnoses, (e.g., pediatric transplants); and (b) An in-state transplant hospital requests the out-of-state transplant referral; and (c) Be cost effective as determined by the Division. For example, if the transplant service is covered by the client's benefit package and the client's primary insurer (i.e., Medicare) requires the use of an out-of-state transplant hospital; or (d) It is a contiguous, out-of-state transplant hospital that has a contract or special agreement for reimbursement with the Division. (5) Professional and other services shall be covered according to administrative rules in the applicable provider guides. (6) Reimbursement for covered transplants and follow-up care for transplant services is as follows: (a) For transplants for fee-for-service clients: (A) Transplant facility services — by contract with the Division; (B) Professional services — at the Division's maximum allowable rates. (b) For emergency services, when no special agreement has been established, the rate shall be: (A) 75% of standard inpatient billed charge; and (B) 50% of standard outpatient billed charge. (c) For clients enrolled in Managed Care Entity (MCE), reimbursement for transplant services shall be by agreement between the MCE and the transplant hospital.