CALIFORNIA - Pacificare Health Systems

Member’s Primary Care Physician/treating
Physician. Depending on the NPTN facility,
the Member may receive post-transplant
services locally or the Member may be
required to travel outside of the Service
Area. If the Member is required to travel
outside the Service Area, PacifiCare will
coordinate travel as appropriate at no
expense to the Member.
6. Continuity of Care
Listing of the Member at a second
PacifiCare National Preferred Transplant
Network facility is excluded, unless the
Regional Organ Procurement Agencies
are different for the two facilities and
the Member is accepted for listing by
both facilities, when associated with
continuity of care. If the Member is dual
listed, his or her coverage is limited to the
actual transplant facility. PacifiCare will
collaborate with the Member to determine
what transplant facility he or she should
be referred to. Duplicated diagnostic costs
at a second PacifiCare National Preferred
Transplant Network facility when the
Member has already been evaluated at a
PacifiCare National Preferred Transplant
Network Facility will be determined on a
case-by-case basis when associated with
continuity of care, hardship or Medically
Necessary as defined by PacifiCare
transplant policy.
7. Case Management and Medical
Management
PacifiCare shall establish and maintain
review procedures and screening criteria
based on scientific evidence. PacifiCare’s
Case Management program will serve the
needs of all Members in terms of:
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Coordination of care
Patient advocacy
Liaison for accurate claims payment
Payment of all services will be contingent
upon PacifiCare’s Case Management
review and Prior Authorization process.
Section 5 – Working With Your
Contracting Medical Providers
8. Exclusions and Limitations
n Equipment and medication that is
experimental/investigational and/or not
Medically Necessary unless required by
an external Independent Review Panel.
Unauthorized or not Prior Authorized
organ procurement and transplantrelated
services are not covered.
Transplants performed in a non-
PacifiCare National Preferred
Transplant Network facility are not
covered.
Transplant services, including donor
costs, when the transplant recipient is
not a Member are not covered.
Artificial or non-human organs are not
covered.
Transportation Services for any day
a Member is receiving Medically
Necessary transplant Services.
Transportation of any potential donor
for typing and matching are not
covered.
Transportation provided for the
Member and one person escort
to a PacifiCare National Preferred
Transplant Facility, if the facility is
greater than 60 (sixty) miles from the
Member’s primary residence, or out
of state regardless of mileage, as Prior
Authorized.
Food and housing will be provided
for the Member and one escort and
is limited to $125 per day (excludes
liquor and tobacco).
Food and housing costs for any day
a Member is not receiving Medically
Necessary transplant services are not
covered.
Storage costs for any organ or bone
marrow are not covered unless
authorized by the PacifiCare Transplant
Medical Director.
Questions? Call the Customer Service Department at 1-800-228-2144,
(TDHI) 1-800-685-9355, Monday through Friday, 7:00 a.m. to 9:00 p.m.
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PART B