Clinical guideline (CG-ANC-07) effective July 1, 2019

Anthem will implement the following clinical guideline, effective July 1, 2019, to support the review for unnecessary inter-facility transfers. This guideline impacts our commercial PPO and HMO products.

 

The inpatient services addressed in this clinical guideline will require prior authorization prior to the inter-facility transfer.

 

Inpatient inter-facility transfers (CG-ANC-07)

This guideline 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).

 

Inter-facility 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 his or her 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 more quickly); or
• The individual has received care at a specific 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.

 

Inter-facility maternal transfer to allow birth mother to remain with neonate is considered medically necessary when neonate transfer meets the medically necessary criteria listed above and the birth mother requires continued hospitalization due to birth complications or other medically necessary conditions.

 

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

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