Kidney Transplant Information Checklist

Service Type: 0300

Provider Contact Name: Provider NPI # Phone Number --

Facility Name where transplant will occur: NPI#

Is this a Retro Review: Yes No

All 0300 requests will be enteredinto Atrezzo system under Physician NPI

  1. End-stage renal disease (ESRD): Yes No
  2. On dialysis or GFR < 20? Yes No
  3. Cardiac screen? Yes No
  4. History of CAD? Yes No
  5. If the answer to 4 is yes, has the member been cleared by cardiologist for transplant? Yes No
  6. GI screen? Yes No
  7. Any GI diseases? Yes No
  8. If the answer to 7 is yes, please list the GI disease:
  9. If the answer to 7 is yes, has the member been cleared by surgeon / gastroenterologist? Yes No
  10. Liver screen? Yes No
  1. Normal serum transaminases and total bilirubin? Yes No
  2. Hepatitis serologies negative? Yes No
  1. Genitourinary Screen? Yes No
  2. Genitourinary diseases? Yes No
  3. If the answer to 12 is yes, please list the genitourinary disease:
  4. GU disease test results were: Negative Positive
  5. Are there minor GU abnormalities? Yes No
  6. GU disease was treated? Yes No
  7. If the answer to 16 is no, please explain:
  8. Will adequate supervision will be provided to assure there will be strict adherence to the medical regimen which is required: Yes No
  9. Medical management has failed and the transplant likely to prolong life and restore a range of physical and social function suited to activities of daily living? Yes No

Created April 2012

Kidney Transplant Information Checklist

  1. Is there a history of drug abuse? Yes No
  2. Is there a history of alcohol abuse? Yes No
  3. Is there a history of smoking? Yes No
  4. If the answer to 15 is yes, has there been a drug free period? If yes, how long?
  5. If the answer to 16 is yes, has there been an alcohol free period? If yes, how long?
  6. If the answer to 17 is yes, has there been a smoke free period? If yes, how long?
  7. Is there a behavioral health disorder by history and PE? Yes No
  8. If the answer to 26 is yes, has the behavioral health disorder been treated? Yes No
  9. Is there adequate social /family support? Yes No
  10. Is there a history or a current serious issue with non-compliance with medical treatment? Yes No
  11. The facility performing the transplant with appropriate credentials and expertise has evaluated the member and has indicated the willingness to undertake the procedure: Yes No
  12. Psychosocial evaluation completed documenting the mental stamina to comply with post transplant treatments: Yes No
  13. Patient understanding of surgical risk and post procedure compliance and follow−up? Yes No

Out of State Providers

  1. Please select one of the four responses which best meets the reason you are requesting Out of State Provider Services and specify how the request meets the selected reason:

Services provided out of state for circumstances other than these specified reasons shall not be covered.

The medical services must be needed because of a medical emergency;

Medical services must be needed and the Member's health would be endangered if he were required to travel to his state of residence;

The state determines, on the basis of medical advice, that the needed medical services, or necessary supplementary resources, are more readily available in the other state;

It is the general practice for Members in a particular locality to use medical resources in another state.

Explain selected response:

  1. Enrolled in Virginia Medicaid: Yes No

Out of state providers may enroll with Virginia Medicaid by going to:

https://www.virginiamedicaid.dmas.virginia.gov/wps/myportal/ProviderEnrollment. At the top of the page, click on Provider Services and then Provider Enrollment in the drop down box.It may take up to 10 business days to become a Virginia participating provider.

Created April 2012