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.

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.

The Death-Graft Failure Notification Form is to be completed for all transplant recipients upon death, or in the event of a graft failure.