Admission, Discharge, and Transfer Notifications for Hospitals, Psychiatric Hospitals and Critical Access Hospitals (CAHs) Interpretive Guidance

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

CMS issued QSO-21-18-Hospitals/CAHs on Friday, May 7, 2021.  This is an advance copy of Interoperability and Patient Access Rule – Admission, Discharge, and Transfer Notifications for Hospitals, Psychiatric Hospitals, and Critical Access Hospitals (CAHs) Interpretive Guidance.

The Interoperability and Patient Access final rule (CMS-9115-F) published May 1, 2020, includes Conditions of Participation (CoPs) for hospitals, psychiatric hospitals, and CAHs. These providers will be required to send electronic patient event notifications of a patient’s admission, discharge, and/or transfer to another healthcare facility or to another community provider or practitioner. These additional requirements will allow hospitals and CAHs to improve care coordination by allowing a receiving provider, facility, or practitioner to reach out to the patient and deliver appropriate follow-up care in a timely manner. The effective date of these new requirement is May 1, 2021.

The new CoPs are included in the medical records requirements at 42 CFR 482.24(d)(1-5) for hospitals, 42 CFR 482.61(f)(1-5) for psychiatric hospitals, and 42 CFR 485.638(d)(1-5) for CAHs. The SOM will be updated with the new guidance and regulatory references in Appendix A and Appendix W.

Hospitals and CAHs that do not meet the electronic health records or administrative system requirements of the content exchange standard, would not be subject to meeting these requirements.

Contact: For any additional questions for concern, please contact

Effective Date: Immediately. This policy should be communicated with all survey and certification staff, their managers and the State/Regional Office training coordinators within 30 days of this memorandum.

Additionally, CMS has also posted Interoperability and Patient Access Final Rule … FAQs on May 7, 2021. The FAQs pertaining to the ADT notifications can be found of pages 10 – 16, starting with question #16.