Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1163 - INPATIENT HOSPITAL SERVICES
Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM
PAYMENT FOR HOSPITAL SERVICES
Section 1163.58 - Payment policy for transfers

Universal Citation: 55 PA Code ยง 1163.58

Current through Register Vol. 54, No. 44, November 2, 2024

(a) For purposes of this chapter, a transfer is limited to those instances in which a patient is transferred between two hospitals both of which are paid under the MA prospective payment system.

(b) Except as specified in subsection (g), if an inpatient is transferred, the hospital that discharges the inpatient as defined in § 1163.51 (relating to general payment policy) is paid the full DRG rate established under this chapter.

(c) Except as specified in subsections (e) and (f), if an inpatient is transferred, the transferring hospital is paid the lesser of one of the following:

(1) A per diem rate for each day of inpatient care determined by dividing the hospital's appropriate DRG payment rate for the case by the Statewide average length of stay for the DRG.

(2) The hospital's appropriate DRG payment rate as determined under this chapter.

(d) In computing the per diem payment specified in subsection (c), the day of transfer is a noncompensable day unless it is also the day of admission.

(e) If the case being transferred is classified into DRG 385 or DRG 456 and is transferred, the transferring hospital is paid the full DRG rate.

(f) A hospital transferring a patient is paid the full DRG rate established under this chapter only if:

(1) The patient was admitted to the hospital by way of a transfer from the acute care setting of another hospital paid under the DRG payment system.

(2) The patient is classified into one of the DRGs from 386 through 390 inclusive or 457 through 460 inclusive.

(g) If a patient has been transferred to a hospital under the conditions set forth in subsection (f), the discharging hospital is paid the lesser of one of the following:

(1) The DRG payment rate for the case.

(2) An amount determined by:
(i) Dividing the hospital's DRG payment rate by the Statewide average length of stay for the DRG.

(ii) Multiplying the amount determined in subparagraph (i) by the number of days in the hospital.

(iii) Multiplying the amount determined in subparagraph (ii) by .60 to establish a marginal per diem payment amount for the hospital.

This section cited in 55 Pa. Code § 1163.51 (relating to general payment policy).

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