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25.2.2.2 Client Transfers
When more than one hospital provides care for the same client, the hospital providing the most significant amount of care receives consideration for a full DRG payment. The other hospitals are paid a per diem rate based on the lesser of the mean length of stay for the DRG or eligible days in the facility. Services must be medically necessary and are subject to the Texas Medicaid Program's UR requirements.
HHSC performs a postpayment review to determine if the hospital providing the most significant amount of care received the full DRG. If the review reveals that the hospital providing the most significant amount of care did not receive the full DRG, an adjustment is initiated.
Client transfers within the same facility are considered one continuous stay and receive only one DRG payment. The Texas Medicaid Program does not recognize specialty units within the same hospital as separate entities; therefore, these transfers must be billed as one admission under the provider identifier. Readmissions to the same facility within 24 hours of a previous acute hospital or facility discharge are also considered one continuous stay and receive only one DRG payment. Readmissions are considered a continuous stay regardless of the original or readmission diagnosis. The modifier PT may appear on the provider's Remittance and Status (R&S) report to indicate that the DRG payment was calculated on a per diem basis for an inpatient stay because of patient transfer. Admissions billed inappropriately are identified and denied during the UR process and may result in intensified review.
Note: To ensure correct payor identification, providers that receive transfer patients from another hospital must enter the actual date that the client was admitted into each facility in Block 12 on the UB-04. Inpatient authorization requirements are based on the requirements that are specified by the program in which the client is enrolled on the date of the original admission. Providers must adhere to the authorization requirements for claims to be considered for reimbursement. Providers are reimbursed at the rate in effect on the date of admission.
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