CurrentExcellus Health Plan IncPolicy 11.01.18

Interfacility Transfer of a Registered Inpatient

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This policy governs coverage of transferring a registered inpatient between acute care facilities for medically necessary specialized diagnostic or therapeutic services. It addresses the transferred admission and hospital stays, not the transportation service itself.

Policy Summary

PayerExcellus Health Plan Inc

PolicyInterfacility Transfer of a Registered Inpatient

Policy CodePolicy 11.01.18

Change TypeAnnual reviewno material clinical or coverage change

Effective DateMarch 19, 2026

Next Review DateMarch 1, 2027

Key ActionObtain prior authorization before transfer when the member's subscriber contract requires it.

SourceLink

POLICY UPDATE CHANGES

Previous newborn transfer eligibility policy statements were moved to policy guidelines.

A formatting correction was recorded in the policy history.

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CurrentExcellus Health Plan IncPolicy 11.01.18

Interfacility Transfer of a Registered Inpatient

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Sign up for excellus_health_plan_inc Policy 11.01.18 alerts

Get alerted when Policy 11.01.18 changes without checking for updates manually.

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Policy Summary

PayerExcellus Health Plan Inc

PolicyInterfacility Transfer of a Registered Inpatient

Policy CodePolicy 11.01.18

Change TypeAnnual reviewno material clinical or coverage change

Effective DateMarch 19, 2026

Next Review DateMarch 1, 2027

Key ActionObtain prior authorization before transfer when the member's subscriber contract requires it.

SourceLink

POLICY UPDATE CHANGES

Previous newborn transfer eligibility policy statements were moved to policy guidelines.

A formatting correction was recorded in the policy history.

2Required criteria for standard covered interfacility transfer

50 miles / 1 hourNewborn return-transfer distance or driving-time threshold

3 daysNewborn convalescent-care threshold

Not coveredElective or convenience transfers

0Applicable procedure and diagnosis codes

Covered Interfacility Transfer Criteria

Standard medically necessary interfacility transfer

Both criteria must be met for the interfacility transfer and both hospital stays to be eligible for coverage.

Standard covered interfacility transfer

Necessary service unavailable at current facility: The necessary specialized diagnostic and/or therapeutic services are not available in the facility in which the patient is registered.
Nearest participating capable facility: The provider of the necessary services is the participating facility nearest to the facility in which the patient is currently admitted that has the required capabilities.

Transfer of mother when newborn requires higher-level care

If a newborn is transferred to a second facility for a higher level of care, transfer of the mother is medically necessary unless the mother's medical discharge is anticipated within 24 hours.

Maternal transfer following newborn transfer

Newborn transferred for higher level of care: The newborn is transferred to a second facility for a higher level of care.
Mother's discharge not anticipated within 24 hours: The mother's medical discharge is not anticipated within 24 hours.Discharge not anticipated within 24 hours

Newborn return transfer to birth hospital

A newborn returning to the birth hospital after medically necessary tertiary care may be covered when tertiary care is complete and the stated distance/time and disposition conditions are satisfied.

Newborn return transfer after tertiary care

Tertiary care completed: The newborn has completed tertiary care according to InterQual Acute Pediatric criteria for Level III or Level IV NICU care.Level III or Level IV NICU care
Return-transfer qualifying pathway
- Distance and convalescent-care pathway
  - Birth hospital distance: The birth hospital is greater than 50 miles or one hour driving time from the tertiary care facility.>50 miles or >1 hour driving time

Receiving-facility selection

Use the nearest participating facility able to provide the necessary care unless an inability to accept, lack of capacity, refusal, or other extenuating circumstance supports use of the next nearest capable facility.

Nearest participating facility available: Use the nearest participating facility that can provide the necessary care.
Next nearest facility due to exception: If the nearest participating facility cannot accept the patient because of inability, lack of capacity, or refusal, transfer the patient to the next nearest participating facility that can provide the necessary care.
Document the circumstances and obtain Health Plan Medical Director review.

Interfacility transfers for reasons other than obtaining necessary specialized diagnostic or therapeutic services are not medically necessary. As a result, the admission to the receiving facility is not eligible for coverage.

Elective or convenience interfacility transfers are not covered.

A transfer of a registered inpatient for a diagnostic procedure designated by the Health Plan as an outpatient procedure is not considered an interfacility transfer when the patient does not meet the InterQual® Acute Inpatient Level of Care Criteria.

Approval of a medically necessary interfacility transfer does not automatically approve the related ambulance transportation. The ambulance mode—air or land/ground—requires a separate clinical review under the applicable ambulance policy.

Transfers for any reason other than obtaining necessary specialized diagnostic or therapeutic services are considered not medically necessary, and the receiving-facility admission is not eligible for coverage.

Elective or convenience transfers are not medically necessary or covered, including returning a patient to the originating facility when the return transfer is not medically necessary.

Codes and Operational Thresholds

CPT CodesCPT

No codes listed

HCPCS CodesHCPCS

No codes listed

ICD10 CodesICD-10

No codes listed

Newborn Return-Transfer Distance or Driving Time

Distance thresholdThe birth hospital must be greater than 50 miles from the tertiary care facility.

Driving-time thresholdThe birth hospital must be more than one (1) hour driving time from the tertiary care facility.

Applicable transferThis threshold applies to an eligible newborn interfacility transfer returning to the birth hospital after medically necessary tertiary care.

Newborn Convalescent-Care Duration

Minimum anticipated stayThe newborn is anticipated to remain in the receiving facility for at least three (3) days.

Purpose of stay

Authorization, Documentation, and Denial Risks

Prior Authorization

Contract-Required Authorization

Obtain prior authorization before transfer when the member’s subscriber contract requires authorization for an interfacility transfer. Some contracts exclude coverage for transfers between health care facilities.

Prior Authorization

Emergency-Room Admission May Still Require Authorization

Routing a registered inpatient through the emergency room does not negate prior authorization requirements when the member contract requires authorization for inpatient admissions and emergent services are not needed.

Documentation Required

Complete Transfer Documentation

Policy Background

An interfacility transfer is the movement of a registered hospital inpatient from one acute care facility to another acute care facility to obtain medically necessary specialized diagnostic or therapeutic services. The receiving facility should generally be the nearest participating facility able to provide the required care. This policy addresses the transferred admission and hospital stays; approval of the transfer is separate from approval of the transportation service or its mode.

Key Definitions and Scope

Interfacility Transfer

PatientA registered hospital inpatient.

Receiving facilityAnother acute care facility.

PurposeTo obtain medically necessary, specialized diagnostic or therapeutic services.

DocumentationThe transferring physician should ensure that all required documentation relating to the transfer of patients is completed.

Policy Scope

Policy focusThe policy addresses the transferred admission of a patient from one acute care facility to another acute care facility.

Covered subject

Policy Summary

PayerExcellus Health Plan Inc

PolicyInterfacility Transfer of a Registered Inpatient

Policy CodePolicy 11.01.18

Change TypeAnnual reviewno material clinical or coverage change

Effective DateMarch 19, 2026

Next Review DateMarch 1, 2027

Key ActionObtain prior authorization before transfer when the member's subscriber contract requires it.

SourceLink

On This Page

Expected convalescent care: The newborn is anticipated to remain in the receiving facility for at least three days for convalescent care.At least 3 days

Tertiary-facility bed-space pathway: Bed space is needed in the tertiary care facility, and the newborn can be safely cared for in the receiving acute hospital.

The anticipated stay must be for convalescent care.

Applicable transferThis duration criterion applies to the newborn return-transfer pathway following completion of medically necessary tertiary care.

The transferring physician should ensure that all required documentation relating to the patient’s transfer is completed.

Documentation Required

Document Exception to Nearest-Facility Rule

Use the nearest participating facility capable of providing the necessary care unless an exception applies. Document the nearest facility’s inability, lack of capacity, or refusal to accept the patient; transfer to the next nearest capable participating facility and obtain required Health Plan Medical Director review.

Denial Risk

Transfer Must Be for Necessary Specialized Services

An interfacility transfer for any reason other than obtaining necessary, specialized diagnostic or therapeutic services is not medically necessary. Admission to the receiving facility is not eligible for coverage.

Denial Risk

Elective or Convenience Transfer

Coverage is not available for elective or convenience interfacility transfers, including transferring a patient back to the originating facility when the transfer is not medically necessary.

Denial Risk

Standard Medical-Necessity Criteria Not Met

Both hospital stays are eligible only when the transfer is medically necessary and both criteria are met: the required specialized services are unavailable at the current facility, and the receiving provider is the nearest participating facility with the required capabilities.

The necessary diagnostic or therapeutic services are not available at the facility where the patient is registered.
The receiving provider is the nearest participating facility to the current facility that can provide the necessary services.

Denial Risk

Outpatient-Level Diagnostic Procedure

A transfer of a registered inpatient to another facility for a diagnostic procedure designated by the Health Plan as an outpatient procedure is not considered an interfacility transfer when the patient does not meet the InterQual® Acute Inpatient Level of Care Criteria.

Coverage may be denied when the procedure is outpatient-level and the patient is not admitted as an inpatient under the applicable acute inpatient criteria.

Prior Authorization

Emergency-Room Routing Does Not Waive Authorization

Accepting a registered inpatient through the emergency room does not remove prior authorization requirements when emergent services are not needed and the member contract requires authorization for inpatient admissions.

It concerns the transfer of a registered inpatient to obtain medically necessary, specialized diagnostic or therapeutic services.

Not addressedThe policy does not address coverage of transportation of a registered inpatient.