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Reimbursement Available for Organ Acquisition Services

Monday, October 28, 2019

TRICARE covers organ transplants as a limited benefit. Effective Oct. 28, 2019, TRICARE will offer reimbursement for reasonable and necessary organ acquisition services and costs in support of quality organ transplant programs. Under Medicare, certified transplant centers (CTCs) and organ procurement organizations (OPOs) report these costs using the Centers for Medicare and Medicaid Services (CMS) Forms 2552 (CTCs/hospital-based OPOs) and 216 (independent OPOs). However, since TRICARE does not have any reporting mechanisms in place comparable to Medicare’s for such costs, Medicare Standard Acquisition Charges (SACs) will be used to determine reimbursement amounts. 

TRICARE will pay CTCs a prospective payment rate to get the organs. The CTCs must develop two Medicare SACs based on reasonable and necessary organ acquisition costs:

  1. A Medicare SAC for acquiring a living donor organ (estimated average charge for services provided to living donors and recipients of living donor organs)
  2. A Medicare SAC for acquiring a cadaveric donor organ (estimated average charge for procuring cadaveric organs combined with expected costs of acquiring cadaveric organs from other sources)

The SACs cover total costs for getting either live or cadaver organs. Solid organ procurement costs must be billed separately with revenue code 081X and Healthcare Common Procedure Coding System (HCPCS) code S2152 to be eligible for reimbursement.

TRICARE reimburses CTCs for organ acquisition one of two ways:

  1. Annually, providers should report Medicare SACs to the TRICARE managed care support contractor for organ acquisition costs for the fiscal year (Aug 1–July 30). HNFS is the West Region contractor.
  2. If the provider is unable to report Medicare SACs (a reason is required), TRICARE will use the hospital’s overall operation cost-to-charge ratio (CCR) to reduce charges.

Please review the Organ Acquisition Costs section of the TRICARE Reimbursement Manual (Chapter 1, Section 40) for details. For additional benefit information, visit our Transplant Details page.