Ga. Medicaid Part II Policies & Procedures for Hospital Services § 907

When covered services are not available or provided in the hospital where the member is an

inpatient or outpatient, the services must be furnished by another enrolled hospital through a

contractual agreement. The original hospital where the member is an inpatient or outpatient must bill

the Medicaid program for the shared services or procedures along with the other charges incurred

during that course of treatment or inpatient confinement. The Medicaid program should only be

billed by the original hospital for all of the charges incurred. Services furnished “under

arrangement” with outside suppliers, including other providers, are subject to CMS-15, Provider

Reimbursement Manual, principles of reimbursement.

907.1. Hospital Back Transfers

The department may approve transfers from a higher level of care facility to the originating

lower level of care facility for continuation of a lower level of care, provided the:

907.1.1. Higher level of care is no longer warranted,

907.1.2. Level of care continues to meet the criteria for inpatient confinement, and

907.1.3. Transfer back does not compromise patient care.

907.1.4. This is intended to provide a mechanism for Georgia Medicaid members to

receive medically necessary level of care in the most appropriate setting and

does not serve to replace or otherwise circumvent the terms and conditions

outlined in Section 903.2: Shared Available Through Contractual Shared

Agreement. This policy is not meant to allow transfers to lower level of care

facilities to alleviate bed overcrowding or for patient convenience. All transfers

are subject to precertification in accordance with Section 800.

907.1.5. See Section 1013 for transfer cases for reimbursement of Hospital Back

Transfers.

907.2. Transplant Services

Services and supplies related to covered transplant services may be billed to the

Division as long as the individual receiving the transplant is eligible for Medicaid. For

Medicaid members under age twenty-one (21) years of age, all recognized, non-

experimental organ transplants are covered if medical necessity is properly documented,

and precertification/prior approval is obtained. For Medicaid members twenty-one (21)

years of age and over, the only transplants covered are kidney, liver, bone marrow and

cornea. Non-covered transplant services are not covered if Medicaid did not pre-certify

the transplant, then any subsequent charges or follow-up care is non-covered per

Medicaid Policy. See Chapter 800 for precertification requirements.

Hospital services in connection with the acquisition of tissue or an organ from a living

donor for transplant in an eligible member are considered as services for the treatment

of the member and are covered as such, although the donor may or may not be Medicaid

eligible.