CurrentIndependent HealthPolicy N/A

Inpatient Request to Transfer to Out of Area Facility

Form and process for requesting an inpatient transfer of a member to an out-of-area (non-local) receiving facility; affects referring/transferring and receiving facilities, referring physicians, and Independent Health utilization management staff processing transfer requests.

Policy Summary

PayerIndependent Health

PolicyInpatient Request to Transfer to Out of Area Facility

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the Inpatient Request to Transfer to Out of Area Facility form via phone or fax and indicate expedited status with rationale if requested.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1phone number for transfer requests

1fax number for transfer requests

1required documentation attachment instruction

Expedited optionexpedited status checkbox present

Member, Transferring, Receivingsections on form

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Transfer Request Processing Requirements

Transfer request processing requirements

Information required to process a transfer request and when expedited handling applies.

All fields marked with * on the Inpatient Request to Transfer to Out of Area Facility form must be completed to avoid delay of determination.

Required submission information: provide member details, transferring facility information (name, NPI, referring physician), and receiving facility information (name, NPI, address).

Attach comprehensive clinical documentation supporting the request for admission or continued stay (examples: history & physical, consults, laboratory results, and other pertinent clinical records).

Provide contact method used to submit the form (phone or fax): phone (716) 631-3282; fax (716) 631-5329.

Expedited handling: Expedited status may be requested by selecting the expedited checkbox and providing a rationale.

Expedited determination threshold: Expedited requests are appropriate when the time frame could seriously jeopardize the life or health of the member; include rationale when requesting expedited review.

Coding and Expedited Determination

No specific billing or diagnosis codes referencedmixed

No codes listed

Expedited determination threshold — Inv-03: When to use expedited handling

Expedited thresholdUse expedited determination when the time frame could seriously jeopardize the life or health of the member; select the 'YES' expedited checkbox and provide a rationale on the form.

Form controlThe form includes a checkbox option: NO or YES and a free-text rationale field to document why expedited status is requested.

Action required from requesterIf expedited is selected, the requester must provide a clear rationale describing how delay would jeopardize life or health.

Submission Requirements and Contact

Prior Authorization

Submit transfer form (phone/fax), indicate expedited status, and attach clinical documentation

Complete and submit the Inpatient Request to Transfer to Out of Area Facility form by phone or fax; indicate whether expedited status is requested and provide a rationale if yes. Include member, transferring facility, and receiving facility details, and attach comprehensive clinical documentation (H&P, consults, labs, etc.).

Submit via Phone: (716) 631-3282 or Fax: (716) 631-5329.
Select the expedited checkbox and provide a rationale when the time frame could seriously jeopardize the life or health of the member.
Complete all fields marked with * to avoid delay of determination.
Attach comprehensive clinical documentation supporting the request (H&P, consults, lab results, etc.).
Provide required transferring facility and receiving facility information (names, NPIs, TAX IDs, referring/accepting physician details, anticipated transfer date).

Expedited

Expedited — definition and handling note

DefinitionExpedited request: a request submitted with expedited status when the time frame could seriously jeopardize the life or health of the member.

Form noteThe request form asks 'DOES THIS REQUEST REQUIRE EXPEDITED STATUS?' with NO / YES options and a space for rationale.

Documentation expectationRegardless of expedited status, attach comprehensive clinical documentation (H&P, consults, lab results, etc.) to support the request.