Non-Emergency Facility to Facility Transfers
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This policy governs medical necessity review and prior authorization requirements for non-emergency transfers between healthcare facilities. It applies to transfers involving participating and non-participating facilities under HAP CareSource Michigan Coordinated Health.
The policy underwent periodic review and its references were updated.
Non-Emergency Transfer Coverage
Medical necessity criteria for reviewed transfers
Covered after medical necessity review when the member is medically stable for transfer and at least one qualifying criterion is met.
Reviewed transfer medical necessity
Qualifying transfer reason
- 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.
- Return to prior institution: The member requires transfer because care was received at a specific prior institution for a condition not normally managed at the originating facility, and return to that institution is needed to diagnose, manage, or treat a complication or other acute issue.
- Improve health and welfare: The member requires transfer to improve the health and welfare of the member, such as parental bonding.
- Parent remains with transferred neonate: Transfer to allow a parent who gave birth to remain with the neonate is medically necessary when the neonate transfer meets the medical necessity criteria and the parent requires continued hospitalization due to birth complications or other medically necessary conditions.
Applies to the parent transfer in the specified neonatal circumstances.
Non-covered elective transfers
Non-emergency elective transfers are not covered when either condition applies.
Non-covered elective transfer conditions
- Criteria not met: The applicable medical necessity criteria have not been met.
- Transfer for convenience: The transfer is for the convenience of the member, the member's family, the physician, or the originating facility.
Transfer, admission, and subsequent care at the receiving facility are not medically necessary when the needed care is available at the originating facility.
Inter-facility transfers within the same healthcare system and intra-facility transfers within the same facility do not require medical necessity review.
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 also 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 physician, or the originating facility.
Authorization and Transfer Requirements
Receiving facility must submit prior authorization
For non-emergency transfers that require medical necessity review, the receiving facility must submit the prior authorization request to CareSource.
- Medical necessity review is required for transfers from a participating inpatient facility to a participating inpatient facility that is not within the same healthcare system.
- Review is also required for transfers from a non-participating facility to a participating facility or to another non-participating facility.
Avoid non-covered elective transfers
A non-emergency elective transfer is not a covered service 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 physician, or the originating facility.
- The member must be medically stable for transfer and meet the applicable medical necessity criteria.
- Transfer, admission, and subsequent care at the receiving facility are not medically necessary when the needed care is available at the originating facility.
Policy Scope and Purpose
This policy addresses the medical necessity of transferring a patient to a second acute care facility when the required care is unavailable at the original facility. Transfers should support the patient's optimal health by using the nearest facility that provides the highest specialized care needed, while maintaining continuity of care through appropriate transfer decisions, communication, pre-transfer stabilization and preparation, transport arrangements, monitoring, documentation, and handoff at the receiving facility.
Transfer and Facility Terms
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