Heart (Adult) Candidate Summary
Heart (Pediatric) Candidate Summary
Heart-Lung Candidate Summary
Single/Double Lung Candidate Summary
Liver Candidate Summary
Pancreas Candidate Summary
Small Bowel-Intestine Candidate Summary
Instructions for submitting candidate clinical reviews
Standard Criteria
Medically Urgent Criteria
Medically Urgent CD Committee Narrative & Presentation Guidelines
Ohio CD Contract
OSOTC Chemical Disorder Criteria
Ohio Medicaid Required Information Form
The following information is required by Ohio Medicaid for patients seeking prior authorization for extra renal transplant. All information indicated 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.
This form may be uploaded to the online review system https://review.osotc.org along with the clinical summary -OR- it may be emailed to: [email protected]
Please note: This form is only required when Ohio Medicaid is the PRIMARY insurer.
Out-of-State Medicaid Justification
Per the Ohio Department of Job and Family Services contract for services C-1213-07-0043, Article 1, A(4), in accordance with Ohio Administrative Code 5101:3-2-07, only extra renal organ transplants to Ohio Medicaid consumers, that cannot reasonably be performed in Ohio, will be sent out-of-state. The following information is needed as justification for your Ohio Medicaid patient seeking extra renal organ transplantation outside the state of Ohio.
Please use the Out-of-State Medicaid Justification Form if you are a non Ohio center requesting approval for organ transplant.
Death-Graft Failure Notification Form
The Death-Graft Failure Notification Form is to be completed for all transplant recipients upon death, or in the event of a graft failure.