CurrentBlue Cross Blue Shield - MainePolicy G-13002

DRG Inpatient Facility Transfers

Governs reimbursement when a member is admitted to one acute care facility and subsequently transferred to another acute care facility for the same episode of care; applies to AMH Health (Blue Cross Blue Shield - Maine) claims and providers submitting those claims.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyDRG Inpatient Facility Transfers

Policy CodePolicy G-13002

Change TypeClarificationReview

Effective Date10/13/2021

Next Review Date

Key ActionUse the appropriate discharge status code on the transferring claim to indicate transfer to another acute care facility and follow authorization and medical necessity guidelines.

SourceLink

POLICY UPDATE CHANGES

Language added to treat members who leave against medical advice and are admitted to another acute care facility on the same day as transfers.

Review approved with no changes on 07/07/2023.

Full DRGpayment to receiving facility

Per diempayment to transferring facility

G-13002document identifier

2023-07-07last review

Inpatient Transfer Payment Rules

Inpatient transfer payment criteria

AMH Health payment rules for facility-to-facility inpatient transfers:

ALL of the following

Receiving facility payment
- Receiving facility will receive full DRG payment.
Transferring facility payment
- Transferring facility will receive a calculated per diem rate based on length of stay not to exceed the amount that would have been paid if the member had not been discharged to another setting.
Members who leave AMA

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyDRG Inpatient Facility Transfers

Policy CodePolicy G-13002

Change TypeClarificationReview

Effective Date10/13/2021

Next Review Date

Key ActionUse the appropriate discharge status code on the transferring claim to indicate transfer to another acute care facility and follow authorization and medical necessity guidelines.

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.

Coding, Billing and Documentation Requirements

Coding and billing standardsmixed

No codes listed

Support in medical record

RequirementServices billed with CPT, HCPCS, or revenue codes must be fully supported in the medical record and/or office notes.

Billing systemsUse industry-standard, compliant codes on all claim submissions (CPT, HCPCS, revenue codes).

ConsequencesIf coding/billing guidelines or reimbursement policies are not followed, AMH Health may recover/recoup payment, reject or deny the claim, or adjust reimbursement.

ApplicabilityPolicy applies to both participating and non-participating professional providers and facilities unless otherwise noted.

Superseding rulesPolicy may be superseded by provider, state, federal, or CMS contracts and/or requirements.

Claims Submission and Discharge Status Instructions

Billing Rule

Claims submission and discharge status — Provider billing instructions

Use the appropriate discharge status code on the transferring facility claim to indicate transfer to another acute care facility. Follow any prior authorization or transfer notification requirements for the receiving facility. Ensure the transferring claim and the receiving claim(s) include supporting documentation that demonstrates the medical necessity for transfer and continuity of care.

Use a discharge status code that denotes transfer to another acute care hospital on the transferring claim.
Include the admission date/time and receiving facility name and identifier on both transferring and receiving claims when available.
Follow authorization requirements: obtain and document any required prior authorization for transfers and admissions per payer rules before or immediately after transfer as specified.
Bill services with appropriate CPT, HCPCS, and revenue codes and ensure clinical documentation supports billed services and the reason for transfer.
If coding/billing guidelines or reimbursement policies are not followed, the payer may recover/recoup payment, reject or deny the claim, or adjust reimbursement.

Terminology

Transfer

DefinitionTransfer — admission to one acute care facility and subsequent transfer to another acute care facility for the same episode of care; includes members who leave against medical advice and are admitted to another acute care facility on the same day.

Receiving facility paymentReceiving facility will receive full DRG payment.

Transferring facility paymentTransferring facility will receive a calculated per diem rate based on length of stay, not to exceed the amount that would have been paid if the member had not been discharged to another setting.

Discharge statusThe appropriate discharge status code must be used on the transferring claim to indicate transfer between acute care facilities.

Policy scopeApplies to AMH Health claims for facility-to-facility inpatient transfers unless superseded by contracts or regulatory requirements.