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Medical Hardship Documents

As a Provider that is not included within the Plan's defined network, the Plan must approve transplant care conducted at your facility for documented Medical Hardship cases. Such Medical Hardship cases must be paid according to contract terms negotiated by INTERLINK and agreed to by Plan and Provider. If payment terms cannot be agreed upon within 14 days of your contract proposal to Plan/INTERLINK, then the Plan shall only pay for services at a % of the Medicare Allowable for services provided. INTERLINK shall contact you after you have completed and submitted these forms to intitiate contract negotiations.

The link below provides all forms required to begin the Medical Hardship application process. The first form must be completed by the surgical director of the applicable transplant program, but the second and third forms can be completed by any staff with access to the required information.

The Medical Hardship forms must be completed and sent to INTERLINK within 3 business days after you contact the Plan for benefits or authorization.

Please contact INTERLINK by phone at 800-599-9119 or email if you have any questions or require assistance in completing the applicable forms.

Download: Medical Hardship Packet