Description

This policy provides direction for correct reporting of services when a member is transferred to another facility during an inpatient stay.

At times, hospitals may not have the equipment or capability to provide a necessary service. During an inpatient stay, the member may be transported to another facility as an outpatient to receive the service or procedure before being returned to the original facility where they are inpatient.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will provide reimbursement for services related to interfacility transfers, according to the criteria outlined in this policy.

Reimbursement Guidelines

Blue Cross NC will not separately reimburse another hospital, facility or transport provider for services related to interfacility transfer occurring during an inpatient stay. Professional services at another facility during an inpatient stay are eligible for separate reimbursement. The inpatient facility is responsible for reimbursement of all other services.

Example scenario:

A member is admitted as inpatient to Hospital ABC. A diagnostic test or procedure is required that is not a service Hospital ABC can provide or perform. An ambulance transports the member to Hospital XYZ that performs the diagnostic test or procedure. Once completed, the ambulance transports the member back to Hospital ABC where they remain inpatient. Reimbursement for the diagnostic test, procedure and ambulance transport are included in Hospital ABC’s inpatient payment. Hospital ABC is then responsible for reimbursing the ambulance provider and Hospital XYZ for any services provided. Professionals performing the diagnostic test or procedure at Hospital XYZ are eligible for separate reimbursement.

Rationale

Reimbursement for an inpatient stay includes any other hospital, facility or transport provider services during an interfacility transfer.

Billing and Coding

Blue Cross NC will reimburse professional services at Hospital B, but ambulance and outpatient facility charges must be reported by Hospital A. 

Related policy

Bundling Guidelines

Services Bundled Into Inpatient/Outpatient Stays

Inpatient Readmission

References

cms.gov

History

1/17/2023 New policy developed. Medical Director Approved. Notification 1/17/2023 for Effective Date 3/17/2023. (cjw)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.