This document addresses the clinical features of a hospitalized individual who may require services unavailable at an initial acute care facility (originating facility) necessitating a transfer to a second acute care facility (receiving facility) and receiving subsequent care at the receiving facility.

This document does not address:

• the transport between emergency rooms of individuals requiring critical care; or
• the transfer of individuals to other types of facilities, such as sub-acute, long-term or rehabilitative facilities; or
• the medical necessity of a specific diagnostic or therapeutic procedure, a specific mode of interfacility transportation, or the inpatient level of care.

Note: Please see the following related documents for additional information:

• CG-ANC-04 Ambulance Services: Air and Water
• CG-ANC-05 Ambulance Services: Ground; Emergent
• CG-ANC-06 Ambulance Services: Ground; Non-Emergent
• CG-MED-26 Neonatal Levels of Care

Clinical Indications

Medically Necessary:

Interfacility transfers are considered medically necessary when one or more of the following criteria are met:

• The individual requires a medically necessary diagnostic or therapeutic service (for example, organ transplantation) which is not available at the originating facility; or
• The individual requires a level of care (for example, neonatal care unit or level 1 trauma center) which is not available at the originating facility; or
• The individual requires the services of a specialist to evaluate, diagnose or treat their condition when that specialist is not available in a timely manner at the originating facility (Note: Timeliness of care is a case/individual specific attribute. It may be appropriate for a medically stable individual to await availability of a specialist for several days while a medically unstable individual may require care sooner); or
• The individual has received care at a prior institution for a condition not normally managed at the originating facility (for example, organ transplant recipient) and return to that prior institution is needed to diagnose, manage, or treat a complication or other acute issue.

Interfacility transfer to allow the parent who gave birth to remain with neonate is considered medically necessary when neonate transfer meets the medically necessary criteria listed above and the parent who gave birth requires continued hospitalization due to birth complications or other medically necessary conditions.

Not Medically Necessary:

Interfacility transfers between an originating facility and a receiving facility are considered not medically necessary when:

• The criteria above have not been met; or
• The transfer is primarily for the convenience of the individual, the individual’s family, the physician or the originating facility.

Admission and subsequent care at the receiving facility is considered not medically necessary when:

• The criteria above have not been met; or
• The transfer is primarily for the convenience of the individual, the individual’s family, the physician or the originating facility.

Coding