Commercial

Acute Care Facility Inpatient Transfers
12.04.04a

Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

MEDICALLY NECESSARY

EMERGENCY TRANSFERS
Transfer of a registered inpatient from one acute care facility to another acute care facility for inpatient admission on an emergency basis to obtain necessary specialized diagnostic and/or therapeutic services is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • There is a medical condition that is life or limb threatening or the professional provider deems to be life or limb threatening, and the individual's condition is such that a delay in transfer poses a threat to the individual's survival or seriously endangers the individual's health or could result in serious impairment to the individual's bodily functions and/or serious dysfunction of any of the individual's bodily organs or parts;
  • The necessary diagnostic and/or therapeutic services are not available at the facility in which the individual is admitted as a registered inpatient;
  • The necessary diagnostic and/or therapeutic services are available at the facility to which the individual is being transferred.
  • The individual has been accepted for admission at the nearest appropriate facility that is capable of addressing the individual’s medical needs.
NONEMERGENCY TRANSFERS
Transfer of a registered inpatient from one acute care facility to another acute care facility for inpatient admission on a nonemergency basis to obtain necessary specialized therapeutic services is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • The necessary therapeutic services are not available at the facility in which the individual is admitted as a registered inpatient;
  • The necessary therapeutic services are available at the facility to which the individual is being transferred.
  • The individual has been accepted for admission at the nearest appropriate facility that is capable of addressing the individual’s medical needs.
NOT MEDICALLY NECESSARY

Transfer of a registered inpatient from one acute care facility to another acute care facility for any other reason is considered not medically necessary and, therefore, not covered. Examples of transfers that are considered not medically necessary include, but are not limited to, the following situations:
  • The requirements in this policy are not met, regardless of the individual's condition.
  • The transfer is for the purpose of obtaining a non-covered service.
  • The transfer is primarily for the convenience of the individual or the individual's family or healthcare professional.
  • The transfer is to return the individual back to the originating facility when the facility to which the individual was transferred is capable of addressing the individual’s medical needs.
REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, inpatient transfers are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

MANDATES

This policy is in compliance with federal, state, and local mandates.

Description

Inpatient transfers involve the transfer of a registered inpatient from one acute care facility to another acute care facility.

Emergency transfer refers to the transfer of an individual from one acute care facility to another acute care facility due to the presence of a medical condition that is deemed to be life or limb threatening, and where the transferring facility does not have the necessary specialized diagnostic and/or therapeutic services to effectively treat the member.

References

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 3: Inpatient Hospital Billing. §40.2.4: IPPS Transfers Between Hospitals. Part A: Transfers Between IPPS Prospective Payment Acute Care Hospitals; p.116. [CMS Web site]. Available at: http://www.cms.gov/manuals/downloads/clm104c03.pdf. Accessed May 31, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network. Acute Care Hospital Inpatient Prospective Payment. [CMS Web site]. Available at: http://www.cms.gov/MLNProducts/downloads/AcutePaymtSysfctsht.pdf. Accessed May 31, 2019.

Company Benefit Contracts.

Coding

CPT Procedure Code Number(s)
N/A

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
N/A

HCPCS Level II Code Number(s)
N/A

Revenue Code Number(s)
N/A



Coding and Billing Requirements


Policy History

12/30/2019
12/30/2019
6/2/2021
12.04.04
Medical Policy Bulletin
Commercial
No