The Michigan Department of Health and Human Services (MDHHS) recently released a final policy effective Aug. 1, allowing authorization for return transfers of stabilized infants from a neonatal intensive care unit (NICU) to the community hospital from which the patient was originally transferred or to another community hospital when the original facility is at capacity or not located near the patient’s home. The policy will allow NICU patients to receive care closer to home, reducing the need for family members to travel long distances and supporting NICU bed availability. The MDHHS will reimburse hospital and ambulance providers based on existing reimbursement policy when prior authorization is granted.
A Prior Authorization Certification Evaluation Review (PACER) is required for elective transfers between hospitals. NICU return transfer requests for continuing care at a community hospital will be authorized if a neonatologist provides a written order to transfer to the originating hospital. Newborns delivered in an emergency department and subsequently admitted to another hospital are not considered transferred and do not require a PACER.
Medicaid fee-for-service (FFS) payment methodology will provide a daily rate to the transferring hospital based on the Diagnosis Related Group (DRG) rate, not to exceed the full DRG payment, plus an outlier payment if appropriate. The receiving hospital will be paid the full DRG payment, plus an outlier if appropriate, upon discharge. Medicaid health plans (MHPs) reimburse hospitals based on contractual terms between the MHP and hospitals. MHPs that reimburse hospitals based on the Medicaid FFS payment methodology are subject to alignment with MDHHS payment policies. Out-of-network and noncontracted hospital providers are reimbursed by the MHPs based on Medicaid FFS payment methodology and rates in effect on the date of service. Members with questions should contact Vickie Kunz at the MHA.