Patient Summary


Instructions for submitting candidate clinical reviews

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 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.

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.