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Coverage criteria policies

Transplant travel benefits

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Due to variation in member contracts, check with Member Services for information regarding specific coverage for this service.

Lodging and travel that meets the indications for coverage below, when required for an authorized, covered transplant, may receive some benefit coverage. To receive reimbursement for eligible travel and lodging expenses, the following are required:

  1. An itemized receipt of services must be submitted
  2. For mileage reimbursement, submit actual miles driven with route and destination addresses
  3. A letter explaining what the receipts are for in conjunction with an authorized transplant. Letter should contain the following information:
    1. Member full name
    2. Member Date of Birth
    3. Member Identification number
    4. Dates of Services
    5. Name of venders
    6. Service type (airfare, lodging)
    7. Mileage with starting and ending destination addresses

Coverage

The benefit period for an authorized covered transplant begins with an authorization for testing and evaluation necessary for a transplant and extends through the member’s authorized transplant episode of care (not to exceed one year from the date of the transplant). Coverage for travel and lodging include a designated caregiver to support the member traveling to and from the Centers of Excellence for the transplant.

A transplant episode of care is defined as authorized transplant related services at the approved Centers of Excellence Transplant facility starting at the time of admission for the transplant through post-transplant related care up to one year.

Indications that are covered

Travel and lodging for authorized transplants when the transplant recipient must travel a distance greater than 100 miles from their home address (primary).

Travel for an authorized transplants when the transplant recipient must travel a distance between 50 to 100 miles from their home (primary) address for mileage coverage only for transportation.

Eligible transportation expenses

Coverage is limited to economy/coach class ticket/fare and the following forms of travel are eligible for coverage:

  1. Bus
  2. Train
  3. Airplane
  4. Taxi to and from lodging to and from a designated Center of Excellence for the Transplant.
Mileage

Mileage for driving an automobile is reimbursed at the IRS rate for the most direct route between the member’s home and the designated Center of Excellence for the Transplant.

https://www.irs.gov/tax-professionals/standard-mileage-rates/

Parking fees and tolls paid in relation to travel to and from the designated Centers of Excellence for the Transplant are covered.

Coverage for the health plan member who is the transplant recipient: $100 per day for lodging.

Indications that are not covered

The following lists of services, including but not limited to, are excluded from coverage as part of this benefit:

  • Alcohol
  • Car rental
  • Clothing
  • Entertainment (i.e., movies or rentals, visits to museums, additional mileage for sightseeing, compact discs, games, etc.)
  • Expense for persons other than the patient and his/her covered companion or caregiver
  • Expenses for lodging when member or companion is staying with a relative or friend
  • Gasoline
  • Groceries (i.e., grocery stores, Walmart, K-Mart, Target, etc.)
  • Meals
  • Laundry service/supplies
  • Non-Legible receipts (i.e., lodging)
  • Paper products (i.e., paper plates, paper towels)
  • Parking fees incurred other than at hotel/motel or hospital
  • Personal hygiene items (i.e., toothbrush, deodorant, etc.)
  • Personal service (i.e., child care, house sitting, kennel care, etc.)
  • Shoe/slippers/robes
  • Souvenirs (i.e., T-shirts, sweatshirts, toys, etc.)
  • Telephone bills/calls/phone cards
  • Tobacco
  • Valet Parking
  • Limo service
  • Gym fees
  • Wi-Fi
  • Spa
  • Any service that is an additional charge to the room charge
  • Additional mileage for sightseeing or visits to friends/relatives
  • Any other service not listed in this policy is excluded from reimbursement

If available, codes are listed for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Code

Description

A0090

non-emergency transportation per mile vehicle provided by individual (family member, self, neighbor) with vested interest

A0100

non- emergency transportation, taxi

A0110

non-emergency transportation, bus intra or interstate carrier

A0140

non-emergency transportation and air travel (private or commercial) intra or interstate

A0170

transportation, ancillary; parking, fees, tolls, other

A0180

non-emergency transportation: ancillary: lodging-recipient

A0200

non-emergency transportation: ancillary: lodging-companion

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor/Provider

For in-network benefits to apply to travel for an eligible medically necessary transplant, the transplant must be received from a contracted vendor/provider.

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Policy activity

  • 01/01/2018 - Date of origin
  • 12/01/2018 - Effective date
Review date
  • 12/2018

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