4811.1 For each claim for Medicaid reimbursement involving a beneficiary transfer to another general hospital, DHCF shall pay the transferring hospital the lesser of the otherwise applicable DRG base payment amount or a prorated payment based on the ratio of covered days to the average length of stay associated with the APR-DRG.

4811.2 The transfer calculation shall apply to the transferring hospital according to the following calculation using the national average lengths of stay (ALOS) available with the APR-DRG grouper:

$$\begin{array}{c} \text{TRANSFER PAYMENT} \ = \ (\text{DRG BASE PAYMENT} / \text{NATIONAL ALOS}) \ \times \ (\text{LOS FOR ELIGIBLE DAYS OF THE STAY} + 1) \end{array}$$

4811.3 If the transfer payment adjustment results in an amount greater than the DRG base payment amount without the adjustment, the transfer payment shall be disregarded and the APR-DRG PPS payment amount shall apply.

4811.4 The hospital receiving the beneficiary shall receive the full DRG payment (unless the referring hospital also transfers the beneficiary).

4811.5 All transfers, except for documented emergency cases shall be prior authorized and approved by DHCF, or its designee, as a condition of payment.

SOURCE: Final Rulemaking published at 45 DCR 4141, 4150 (June 26, 1998); as amended by Emergency and Proposed Rulemaking published at 57 DCR 2691 (March 26, 2010) [EXPIRED]; as amended by Emergency and Proposed Rulemaking published at 57 DCR 6837 (July 10, 2010) [EXPIRED]; as amended by Final Rulemaking published at 58 DCR 4323, 4331 (May 20, 2011); as amended by Final Rulemaking published at 59 DCR 15078 (December 28, 2012); as amended by Final Rulemaking published at 63 DCR 5234 (April 8, 2016).