CurrentAnthemPolicy G-13002

DRG Inpatient Facility Transfers

Defines how Anthem reimburses transferring and receiving acute care facilities when a member is admitted to one acute care facility and then transferred to another for the same episode of care; applies to providers under Anthem Blue Cross (California) Medicare Advantage unless superseded by contracts or regulatory requirements.

Policy Summary

PayerAnthem

PolicyDRG Inpatient Facility Transfers

Policy CodePolicy G-13002

Change TypeNo material change

Effective DateOct 13, 2021

Next Review Date

Key ActionUse the appropriate discharge status code on the transferring claim to indicate transfer and ensure services meet authorization and medical necessity requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

per diempayment approach for sending facility

full DRGpayment approach for receiving facility

same-day AMAclaims treated as transfers

discharge codebilling requirement

08/18/2025most recent review status

DRG Inpatient Transfer Payment Criteria

DRG inpatient transfer payment criteria

Payment rules when a member is transferred between acute care facilities for the same episode of care.

Policy applies unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

ALL of the following

Transferring facility receives a calculated per diem rate based on the length of stay, not to exceed the amount that would have been paid if the member had not been discharged to another setting.
Receiving facility receives the full diagnosis-related group (DRG) payment.

Claims for members who leave against medical advice and are admitted to another acute care facility on the same day are considered transfers.

Policy Summary

PayerAnthem

PolicyDRG Inpatient Facility Transfers

Policy CodePolicy G-13002

Change TypeNo material change

Effective DateOct 13, 2021

Next Review Date

Key ActionUse the appropriate discharge status code on the transferring claim to indicate transfer and ensure services meet authorization and medical necessity requirements.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Claims Submission and Authorization Requirements

Prior Authorization

Claims submission and authorization requirements

On the transferring claim, report the appropriate discharge status code that indicates the member was transferred from one acute care facility to another; ensure all services meet authorization and medical necessity guidelines and follow applicable provider, state, federal, or CMS contract requirements.

Use the discharge status code that denotes transfer to another acute care facility on the transferring facility's claim.
Confirm services meet authorization and medical necessity rules and that billing follows industry-standard coding (CPT, HCPCS, revenue codes) supported by the medical record.
Be aware policy may be superseded by provider, state, federal, or CMS contracts or requirements.

General Reimbursement Policy Definitions

DefinitionGeneral Reimbursement Policy Definitions as referenced in Anthem's reimbursement framework; policy developed considering CMS and state contract requirements.

ScopeApplies to reimbursement when a member is admitted to one acute care facility and then transferred to another for the same episode of care; subject to provider, state, federal, or CMS contract requirements.

Payment rolesTransferring facility: calculated per diem based on length of stay; Receiving facility: full DRG payment.

Claims/billing requirementAppropriate discharge status code must be used on the transferring claim to indicate transfer between acute care facilities.

Policy development sourcesDeveloped with consideration of CMS guidance and applicable state contract requirements.

OpenPayer

DRG Inpatient Facility Transfers

DRG Inpatient Transfer Payment Criteria

Coding Expectations

Claims Submission and Authorization Requirements

General Reimbursement Policy Definitions