Non-urgent inpatient hospital transfers will require prior authorization effective Mar. 10, 2025
When a member is receiving non-urgent inpatient care, we’ll soon require prior authorization before their care can be transferred to a different facility. This change will go into effect Mar. 10, 2025, and won’t impact urgent / emergent hospital transfers.
Note: The transfer of a member’s care between facilities is separate from ambulance transportation. An additional authorization request may be needed for the transportation service, depending on the type of transportation – see below for more.
How to submit a hospital transfer request
Either the transferring or receiving facility should submit a new Acute / Emergent authorization request through GuidingCare and include the following information:
- Reason for the transfer
- Accepting attending physician name at the receiving facility
- Other facilities considered if the transfer is out-of-network for the member’s benefit
- Relevant clinical information
- Anticipated mode of transportation
The facility can ask for expedited review after submitting their authorization request in GuidingCare by calling:
- During business hours: Call our provider helpline at 1.800.942.4765.
- After business hours: Call our Utilization Management team directly at 1.800.269.1260.
Urgent / emergent transfers not impacted
There will be no change for urgent / emergent hospital transfers. If a member is experiencing a life-threatening condition and delay of transfer would jeopardize the health of the member, the receiving facility should submit for authorization after the transfer has occurred.
Liability when authorization isn’t received
If prior authorization isn’t approved before a non-urgent inpatient hospital transfer and our team later finds the transfer to be not medically necessary, we’ll cover the stay at the outpatient level of care. The receiving facility will be liable for the difference between the outpatient and inpatient level of care.
Authorizations for transportation between facilities
Prior authorization is required for fixed wing air ambulance transportation. Ground transportation and rotary wing transport as part of a hospital-to-hospital transfer don’t require prior authorization.