Transfer an Infant Out

CCS Information for Transferring

Insurance Plans

Insurance	Definition	Candidate for Non CCS Facility?
KP 1000	Kaiser Plan Insurance from Employer HMO - set copay	Yes
KP 1001	Kaiser Plan Insurance from Employer DHMO - Deductible HMO - Inpatient High $ Deductible	Yes
KP Health Care Reform HMO	Kaiser Plan Purchased by Individual HMO - set Copay	Yes
KP Health Care Reform DHMO	KP Health Care Reform - DHMO Deductible HMO - Inpatient High $ Deductible	Yes
Medical Financial Assistance	Kaiser Charity for those without any insurance. 30 days Kaiser Insurance then must enroll in an insurance after 30 days – Medi-Cal or purchased plan. Contact Case Manager for current insurance eligibility
KP 1003	Kaiser Inland Empire Health Plan Inland Med-Cal Medi-Cal	No*
Inland Empire Health Plan	Medi-Cal	No*

*Note: Unless they do NOT meet CCS criteria below.

CCS Criteria for Critically Ill Neonates and Infants

Critically Ill Neonates

Neonates who do not have an identified CCS-eligible condition but require one or more of the following services in a CCS-approved NICU:

• Invasive or non-invasive positive pressure ventilatory assistance
• Supplemental oxygen concentration by hood of ≥40%
• UAC or Peripheral Art Line
• UVC, Central Venous Catheter, PICC
• Peripheral Line for pharmacological support of the cardiovascular support
• TPN – Central or Peripheral
• Chest Tube

Neonates and Infants

Neonates and infants who do not have an identified CCS-eligible condition but require 2 or more of the following services in a CCS-approved NICU:

• Supplemental inspired oxygen
• Peripheral IV Line for meds, blood products, and/or meds for cardiac support
• Caffeine: Pharmacological support for apnea and/or bradycardia episodes
• Tube feedings

Transfer to Another KP Facility

Discharge summary

Use TRANSFER DISCHARGE SUMMARY NOTE PEDS IP SCAL to compose the discharge summary.

Transfer to a Non-KP Facility

Discharge summary

Use DISCHARGE (CCS) SUMMARY NOTE NICU IP SCAL to compose the discharge summary.