CurrentCareSource GeorgiaPolicy MCD-MM-1447

Non-Emergency Facility to Facility Transfers

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Governs medical necessity review and coverage of non-emergency transfers between healthcare facilities for CareSource Georgia Medicaid members.

Policy Summary

PayerCareSource Georgia

PolicyNon-Emergency Facility to Facility Transfers

Policy CodePolicy MCD-MM-1447

Change TypeTerminology and workflow clarification

Effective DateNov 1, 2026

Next Review DateN/A

Key ActionFor a non-emergency transfer requiring medical necessity review, the receiving facility must submit the request to CareSource.

SourceLink

POLICY UPDATE CHANGES

The policy replaced the term prior authorization with medical necessity review.

The policy replaced references to physician with provider.

3Transfer categories requiring review

2Review-exempt transfer categories

6Qualifying medical necessity criteria

2Non-covered elective transfer situations

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CurrentCareSource GeorgiaPolicy MCD-MM-1447

Non-Emergency Facility to Facility Transfers

Customize your policy alerts

Sign up for caresourcegeorgia Policy MCD-MM-1447 alerts

Get alerted when Policy MCD-MM-1447 changes without checking for updates manually.

Monitor payer policy activity

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Governs medical necessity review and coverage of non-emergency transfers between healthcare facilities for CareSource Georgia Medicaid members.

Policy Summary

PayerCareSource Georgia

PolicyNon-Emergency Facility to Facility Transfers

Policy CodePolicy MCD-MM-1447

Change TypeTerminology and workflow clarification

Effective DateNov 1, 2026

Next Review DateN/A

Key ActionFor a non-emergency transfer requiring medical necessity review, the receiving facility must submit the request to CareSource.

SourceLink

POLICY UPDATE CHANGES

The policy replaced the term prior authorization with medical necessity review.

The policy replaced references to physician with provider.

3Transfer categories requiring review

2Review-exempt transfer categories

6Qualifying medical necessity criteria

2Non-covered elective transfer situations

Non-Emergency Transfer Coverage Criteria

Transfers requiring medical necessity review

Medical necessity review is required for any of the following non-emergency transfer types:

Transfer type requiring review

Participating facility to participating facility outside the same system: Non-emergency transfer from a participating inpatient facility to a participating inpatient facility that is not within the same healthcare system.
Non-participating to participating facility: Non-emergency transfer from a non-participating facility to a participating facility.
Non-participating to non-participating facility: Non-emergency transfer from a non-participating facility to a non-participating facility.

Medical necessity criteria

For a transfer requiring medical necessity review, all of the following must be satisfied:

Medical stability and qualifying indication

Medical stability: The member is medically stable for transfer.
Qualifying medical necessity criterion
- Unavailable level of care: The member requires transfer to a level of care unavailable at the originating facility.
- Unavailable diagnostic or therapeutic service: The member requires transfer for a medically necessary diagnostic or therapeutic service unavailable at the originating facility.
- Unavailable specialist: The member requires transfer for services of a specialist to evaluate, diagnose, or treat a condition when that specialist is not available at the originating facility.

Transfers not requiring medical necessity review

The following non-emergency transfers do not require a medical necessity review:

Review-exempt transfers

Same healthcare system: Inter-facility transfer within the same healthcare system.
Same facility: Intra-facility transfer within the same facility.

Transfer, admission, and subsequent care at the receiving facility are not medically necessary when the needed care is available at the originating facility.

Non-emergency elective transfers are not covered when the stated medical necessity criteria have not been met.

Non-emergency elective transfers are not covered when performed for the convenience of the member, the member’s family, the provider, or the originating facility.

A transfer, admission, and subsequent care at the receiving facility are not medically necessary when the needed care is available at the originating facility.

Review Submission and Denial Risks

Prior Authorization

Submit the medical necessity review request

For a non-emergency transfer requiring medical necessity review, the receiving facility must submit the medical necessity review request to CareSource. The member must be medically stable for transfer and meet at least one qualifying medical necessity criterion.

Review is required for transfers from a participating inpatient facility to a participating inpatient facility outside the same healthcare system, from a non-participating facility to a participating facility, or from a non-participating facility to a non-participating facility.
At least one qualifying criterion must be met, such as an unavailable level of care, diagnostic or therapeutic service, or specialist at the originating facility.

Denial Risk

Avoid unnecessary or convenience transfers

Transfer, admission, and subsequent care at the receiving facility are not medically necessary when the needed care is available at the originating facility. Non-emergency elective transfers are not covered when the medical necessity criteria have not been met or when the transfer is for the convenience of the member, the member’s family, the provider, or the originating facility.

Transfer Policy Background

Inter-facility transfer is intended to move a patient to the nearest facility capable of providing the highest level of specialized care needed when that care is unavailable at the originating facility. Safe transfer also requires continuity of care, including an appropriate transfer decision and communication, pre-transfer stabilization and preparation, suitable transport, accompanying personnel, required equipment and monitoring, documentation, and handoff at the receiving facility.

Key Transfer Definitions

Definition

Inter-Facility TransferThe transfer of patients between two healthcare facilities.

Definition

Intra-Facility TransferThe transfer of patients within the same facility.

Definition

Non-EmergencyA situation for which immediate response is not needed for the provision of medical treatment.

Definition

Non-Participating (Out-of-Network) Facility