9200 Memorial Drive • Plain City, Ohio 43064
Phone (614) 504-5705 • Fax (614) 504-5707 www.osotc.org
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**PLEASE NOTE**
This form is only required when Ohio Medicaid is the PRIMARY insurer.
The following information is required by Ohio Medicaid for patients seeking prior authorization for extra renal transplant. All information indicated below is required . Ohio Medicaid will not issue a prior authorization without this required information.
This form must be submitted to the OSOTC as a Word document . It may be uploaded to the online review system along with the clinical summary at time of review –OR– it may be emailed to: review@osotc.org
Hospital/Billing Provider Information
(NPI Number = 10-digit provider billing#)
Hospital Name:
Address:
Organ:
Transplant Information
(Beginning and Ending Dates of Services MUST be provided in instances where the surgery date is known)
ICD 9 Code ICD 9 Desciption Surgery Date (if known):
NPI Number:
Contact Person:
Contact ’s Number:
Organ: ICD 10 Code ICD 10 Desciption
Requested Eff Date: if surgery date known
Surgery Date (if known):
Requested End Date: if surgery date known
Recipient Information
(Ohio Medicaid# MUST be the 12-digit billing#)
Patient Name:
Ohio Medicaid #:
Date of Birth:
Social Security #:
Address:
(full residential address)
Procedure Codes & Descriptions Instructions
1) Procedure code(s) and description(s) must be selected from the table shown on page 2 of this form. (please enter codes exactly as shown, codes using decimal points cannot be submitted)
2) Only one “Code & Description” should be selected per organ to be transplanted.
3) When multiple organs are to be transplanted, you may select multiple codes if a combination code does not already exist.
4) Copy your selection from the table on page two of this form and paste it into the “Procedure Codes &
Descriptions” area in the table above.
V15.0225
Page 1 of 2

Organs
Heart
Heart-Lung
Lung
Lung
Lung
Liver
Liver
Intestine
Intestine
Pancreas
Pancreas
Pancreas
Pancreas
Code
3751
336
3350
3351
3352
5051
5059
4697
4699
5280
5281
5282
5283
Description
Heart transplantation
Combined heart-lung transplantation
Lung transplantation, not otherwise specified
Unilateral lung transplantation
Bilateral lung transplantation
Auxiliary liver transplant
Other transplant of liver
Transplant of intestine
Other operations on intestines
Pancreatic transplant, not otherwise specified
Reimplantation of pancreatic tissue
Homotransplant of pancreas
Heterotransplant of pancreas
Organs
Heart
Lung Bilateral
Lung Left
Lung Left
Lung Left
Lung Left
Lung Right
Lung Right
Lung Right
Lung Right
Liver
Pancreas
Intestine Large
Intestine Small
Stomach
Code
02YA0Z0
Description
Transplantation of Heart, Allogeneic, Open Approach
0BYM0Z0
0BYL0Z0
0BYG0Z0
0BYH0Z0
0BYJ0Z0
0BYK0Z0
0BYC0Z0
0BYD0Z0
0BYF0Z0
0FY00Z0
0FYG0Z0
0DYE0Z0
0DY80Z0
0DY60Z0
Transplantation of Bilateral Lungs, Allogeneic, Open Approach
Transplantation of Left Lung, Allogeneic, Open Approach
Transplantation of Left Upper Lung Lobe, Allogeneic, Open Approach
Transplantation of Lung Lingula, Allogeneic, Open Approach
Transplantation of Left Lower Lung Lobe, Allogeneic, Open Approach
Transplantation of Right Lung, Allogeneic, Open Approach
Transplantation of Right Upper Lung Lobe, Allogeneic, Open Approach
Transplantation of Right Middle Lung Lobe, Allogeneic, Open Approach
Transplantation of Right Lower Lung Lobe, Allogeneic, Open Approach
Transplantation of Liver, Allogeneic, Open Approach
Transplantation of Pancreas, Allogeneic, Open Approach
Transplantation of Large Intestine, Allogeneic, Open Approach
Transplantation of Small Intestine, Allogeneic, Open Approach
Transplantation of Stomach, Allogeneic, Open Approach