CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Transfers Between DRG Facilities (Inpatient Transfer Payment Criteria)

Defines payment rules for hospitals reimbursed under DRG when inpatient transfers occur between two acute care DRG facilities in the local in-network network; excludes mental health, maternity, and rehabilitation and applies to transfer status 02 and 05.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyTransfers Between DRG Facilities (Inpatient Transfer Payment Criteria)

Policy CodePolicy N/A

Change TypeDocumentation update (no material change)

Effective DateJul 12, 2022

Next Review DateN/A

Key ActionDo not submit prior authorization; prior authorization is not applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

02 & 05transfer statuses to which transfer logic applies

mental health, maternity, rehabfacility types excluded

per diem up to DRGpayment to transferring hospital

full DRGpayment to receiving hospital

reimbursable separatelyprofessional services

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Inpatient Transfer Payment Rules

Inpatient Transfer Payment Criteria

Payment rules for local in‑network DRG‑reimbursed facilities when an inpatient transfer occurs between acute care facilities.

Applies to local in‑network facilities reimbursed as DRG; excludes mental health, maternity, and rehabilitation; transfer logic applies to transfer status 02 and 05.

Individual hospital contract language supersedes this policy.

ALL of the following

Transferring hospital: when a patient is transferred to another acute care facility, the admitting (transferring) facility is paid a per diem rate calculated based on the DRG average arithmetic length of stay (ALOS) divided into the full DRG allowance; per diem payment is up to the full DRG payment. Payment calculations may vary by contractual guidelines.

ALL of the following

Receiving facility: for acute care transfers, the receiving facility that ultimately discharges the transferred patient receives a full DRG payment based on the calculated DRG.

ALL of the following

Patient leaves against medical advice (AMA): if a patient leaves a hospital AMA and is subsequently admitted to a different hospital on the same day, the initial hospital is paid as a transferring hospital using a graduated per diem rate for each day of the stay, not to exceed the full DRG payment.

ALL of the following

Services performed by another hospital, facility, or freestanding provider while the patient remains an inpatient: these services will not be reimbursed separately by BCBSRI unless those services are separately reimbursable when rendered in the inpatient setting (for example, professional services). Reimbursements for all other services are the responsibility of the inpatient facility.

Coding Applicability

Coding applicabilitymixed

No codes listed

Provider Requirements and Actions

Prior Authorization

Prior Authorization — Not applicable

Prior authorization is not applicable for this policy. Providers do not need to submit a prior authorization request for services covered under this policy.

Definitions and Policy Scope

inv-04: Transfers Between DRG Facilities (policy)

Policy scopeAdministrative policy defining payment rules for hospitals reimbursed for inpatient services when transfers occur between two Diagnosis-related group (DRG) facilities.

Effective date noteThe effective date reflects when BCBSRI documented established reimbursement processes and does not represent a change in payment process.

ApplicabilityApplies to hospitals reimbursed as DRG for inpatient transfers between two DRG facilities.

Related guidanceFor coverage of ambulance services related to transfers, see the 'Ambulance Services - Ground' policy.

Contract precedenceIndividual hospital contract language supersedes this policy.

inv-05: Transferring and Receiving Facilities

Transferring hospital (definition)The hospital sending a patient to another acute care facility; paid a per diem rate calculated from the DRG average length of stay up to the full DRG payment; payment calculations may vary by contract.

Receiving facility (definition)The acute care facility that ultimately discharges the transferred patient; receives a full DRG payment based on the calculated DRG.

Per diem calculation detailPer diem amount is calculated based on the average arithmetic length of stay (ALOS) for the assigned DRG divided into the full DRG allowance.

Payment variabilityPayment calculations for the transferring hospital may vary according to contractual guidelines.