District of Columbia program
Getting a transplant approved, here or out of town
DC Medicaid transplants need a separate approval before treatment, including care outside the plan's network.
What it is
DC Medicaid transplants need a separate approval before treatment, including care outside the plan's network.
A transplant can involve several teams and a different hospital. DC Medicaid's quality review organization must approve the transplant. The health plan must cover medically necessary care outside its network when it cannot supply that care.
Eligibility rules
- A child on DC Medicaid, in a health plan or in fee-for-service.
- District of Columbia.
What you get
- Covered transplant care after approval.
- Necessary care outside the network when the network cannot supply it.
If you decide to apply
- Ask the transplant team who is submitting the approval request and record the submission date.
- Ask the Medicaid care manager for written confirmation of the receiving center's coverage.
Transplant team and your child’s Medicaid care manager. Comagine Health DC Medicaid: 800-251-8890. DHCF transplant policy contact: 202-724-8936. · Official page ↗
Travel and agreements
- DC Medicaid requires quality-review approval for covered transplants, whether a health plan or DHCF pays directly. Comagine Health lists the DC service at 800-251-8890; the transplant team confirms the packet and submission route. Procedure approval, an out-of-network payment agreement and travel approval are separate decisions. The plan and receiving hospital arrange plan payment terms; DHCF identifies the authorized signer when it pays directly. The social worker can help obtain written decisions about the center, transport, an attendant, lodging and meals.
Good to know
Ask who is sending the approval request and on what date; a hospital agreeing to treat your child is not the same as Medicaid approving it.
Other details
- For the August 1, 2026 Wellpoint-to-AmeriHealth transition, DHCF protects existing appointments and pre-transition referrals or approvals through October 31, 2026. The transplant team can check whether the existing approval qualifies; new services need separate review.
Official sources
“If a transplant is proposed, what must our plan approve before treatment or travel? Could you help us check the hospital agreement and uncovered costs with the transplant team?”
Why I’m asking: I want to understand what approvals and agreements are needed before treatment or travel.
More background and detailed requirements
Additional program information and published rules
Who does what
The three parts, side by side. The agency decides; nobody on this page does.
You
Ask who submitted it and when, and get the plan's confirmation in writing before you travel.
Your social worker
The transplant team submits the request; the plan's care manager arranges the out-of-network agreement.
The care team
The transplant team documents why this centre is the one.
- Who decides
- The DC Medicaid quality review organisation, then the health plan for the network question.
- Ask your social worker
- “Who has submitted the DC Medicaid transplant authorisation, and on what date? Can the plan confirm in writing that it will cover the out-of-network centre before we travel?”
How to apply
First step: Ask the transplant team today who is submitting the DC Medicaid authorisation and on what date.
- Ask the team who is submitting the transplant approval and on what date.
- Ask the health plan care manager to confirm out-of-network coverage in writing before travel is booked.
- Ask about travel, meals and lodging separately: no District rule on those was found.
Official application / program page ↗
Where it starts: Ask the transplant team who is submitting the prior authorisation and when. The Department of Health Care Finance policy contact is 202-724-8936.
What to gather
The diagnosis letter, the child’s insurance card, and the last two pay stubs cover most applications. The official page lists the rest.
How long: No published clock for a transplant authorisation.
What a yes looks like
A written authorisation naming the centre and the procedure.
What a no looks like, and the next move
Ask for the reason in writing and use the plan appeal, then the District external review.
Watch out
- Ask who submitted the approval and when. Do not assume the receiving centre has done it.
- No District rule on travel, meals or lodging for a distant transplant was found.
If they say no, quote this: DHCF Transmittal 24-02: "All transplantation procedures shall be prior authorized by the DC Medicaid Quality Improvement Organization (QIO)".
The numbers and the rules
The arcane layer, kept on purpose. Checked September 11, 2026.
What it is worth
One approval route for every DC Medicaid transplant, and an out-of-network duty when the network cannot supply the care.
Covers: Transplant coverage once approved · Out-of-network care when the network cannot supply a medically necessary service
Legal protection: The plan must cover out-of-network care until it has a provider agreement in place
What it costs the family: No cost to the family for covered care.
The eligibility facts, as published
- Other
- A child on DC Medicaid, in a health plan or in fee-for-service
- Residency
- District of Columbia
The trap: Ask who is submitting the request and get the submission date. Do not assume the receiving centre has done it.
Where I read this
- DHCF — Transmittal 24-02, Organ Transplantation Coverage — DC Department of Health Care Finance, read September 10, 2026
- DHCF — Managed Care Contract (public copy) — DC Department of Health Care Finance, read September 10, 2026
- DHCF — Medicaid Managed Care Plans (MCPs) — DC Department of Health Care Finance, read September 10, 2026