CurrentBlue Cross Blue Shield - WisconsinPolicy G-13002

DRG Inpatient Facility Transfers

Defines how the health plan reimburses inpatient facility transfers between acute care hospitals for the same episode of care; applies to facilities billing Anthem/BCBSWI for inpatient transfers.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyDRG Inpatient Facility Transfers

Policy CodePolicy G-13002

Change TypeNo material changes

Effective DateOct 13, 2021

Next Review Date

Key ActionEnsure authorization and medical necessity guidelines appropriate to procedure and diagnosis are met and submit claims with proper billing and industry-standard codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

full DRGreceiving facility

per diemtransferring facility

treated as transferAMA same-day

no changes 08/18/2025history note

DRG Inpatient Transfer Reimbursement Criteria

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Policy applies to members admitted to one acute care facility and subsequently transferred to another acute care facility for the same episode of care, unless superseded by provider, state, federal, or CMS contracts or requirements.

ALL of the following

Transferring facility payment: The transferring facility will receive 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 payment: The receiving facility will receive the full diagnosis-related group (DRG) payment.

ALL of the following

Discharge status code: The appropriate discharge status code must be used on the transferring claim to indicate that the member was transferred from one acute care facility to another.
AMA same-day admissions: Claims for members who leave against medical advice and are admitted to another acute care facility on the same day are considered transfers.

Authorization and Billing Guidance

Billing Rule

Authorization, medical necessity, and proper coding/billing required

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence. Use proper billing and submission guidelines, including industry‑standard CPT, HCPCS, and/or revenue codes, and ensure codes billed are fully supported in the medical record and/or office notes. Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, recovery/recoupment of payment, or adjustment of reimbursement to reflect the appropriate services performed.

Obtain any required authorizations and document medical necessity for the procedure and diagnosis before billing.
Bill services with CPT, HCPCS, and/or revenue codes as appropriate and ensure documentation supports the codes billed.
Follow the plan's billing and submission guidelines to avoid rejection, denial, recoupment, or reimbursement adjustment.

Policy Definitions and Special Cases

General Reimbursement Policy Definitions

ScopeGeneral reimbursement policy definitions apply as referenced in the policy.

Source referenceDefinitions section titled 'General Reimbursement Policy Definitions' in the policy document.

ApplicabilityThese general definitions govern interpretation of reimbursement rules within this policy unless superseded by contract, state, federal, or CMS requirements.

UsageReferenced by coverage and claims processing rules throughout the document (e.g., transfer, discharge status, payment methods).

Leave Against Medical Advice (AMA) transfers

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

Claim requirementThe appropriate discharge status code must be used on the transferring claim to indicate transfer from one acute care facility to another.

Operational impactClaims meeting this condition are processed under transfer reimbursement rules rather than standard discharge rules.