The Receiving Hospital Obligation: Accepting an Appropriate Transfer (42 CFR § 489.24(f))

Receiving hospitals are EMTALA gatekeepers whenever a sending facility requests an appropriate transfer for a patient with an emergency medical condition. Under 42 CFR 489.24(f), a hospital with specialized capabilities and capacity must accept the transfer. This responsibility is not optional, and it’s evaluated in real time using the hospital’s actual resources, on-call availability, and the patient’s clinical needs. For small hospitals, “specialized capabilities” might be limited, but the rule still applies if you do possess the relevant capability for the specific patient. The safest, most defensible approach is to maintain a continuously updated snapshot of capacity, to give rapid yes/no decisions tied to that snapshot, and to document the reasoning, the timing, and the intake steps that follow acceptance.

EMTALA obligations don’t end at your ambulance bay; they often begin with a phone call. When a neighboring ED or critical access hospital requests transfer, the receiving hospital must quickly decide whether it has the capability and capacity to care for the patient’s emergency condition. If it does, the hospital must accept. Delays, dithering, or insurance discussions are perilous and irrelevant to the legal standard. This article breaks down the receiving-side duty under 42 CFR 489.24(f) into practical, auditable steps that lean-staffed facilities can deploy without new headcount. The goal is to compress the decision-making window, match the patient to the appropriate service line, and keep records that withstand CMS survey and potential OIG review.

Understanding Legal Framework & Scope Under 42 CFR 489.24(f)

The rule text and its core test. EMTALA’s implementing regulation requires hospitals with specialized capabilities or facilities to accept appropriate transfers if they have the capacity to treat the individual. “Capacity” means more than empty beds; it encompasses on-call coverage, staff, equipment, and the hospital’s ability to move resources within a reasonable timeframe. “Capability” asks whether you can provide the necessary stabilizing care for the patient’s specific emergency condition.

Specialized capability examples. Neurosurgery, PCI-capable cardiology, burn units, neonatal intensive care, psychiatric emergency services, obstetrics with surgical backup, or stroke centers qualify as specialized capabilities. Smaller hospitals may still have niche capability (e.g., 24/7 anesthesia and OR for emergency laparotomy, OB with C-section). If the requested care aligns with your services, the acceptance duty attaches if capacity also exists.

Appropriate transfer by the sender. The sending hospital remains responsible for arranging an appropriate transfer (stabilization within capability, physician certification or patient request, accepting physician identified, qualified transport). But the receiving hospital’s duty to accept turns on its own capability and capacity, independent of whether the sending hospital is large or small.

Federal floor vs state overlay. Trauma or perinatal regionalization policies, state psychiatric bed registries, and EMS diversion protocols can guide routing, but they cannot negate the federal acceptance duty when capability and capacity are present. If state or regional rules appear to conflict, EMTALA’s federal standard controls the acceptance decision, while the hospital simultaneously complies with state reporting or notification processes.

Operational implication. Surveyors review whether your acceptance decision matched reality. If your ICU had staffed beds, your neurosurgeon was on-call, and your OR was available, a refusal will be hard to defend. Conversely, if you were on internal disaster status, lacked on-call coverage, or had zero operating vents, those facts document a legitimate lack of capacity.

CMS enforces EMTALA through State Survey Agencies, using Appendix V to investigate complaints and sentinel events. Confirmed violations may be referred to the HHS Office of Inspector General for civil monetary penalties. Common receiving-side triggers include: refusal despite documented staffed beds and on-call availability; repeated refusals from a particular service line; delays linked to insurance status; and diversion claims not substantiated by internal incident logs. Surveyors triangulate bed management dashboards, on-call schedules, nursing assignment sheets, and call logs to determine whether you had capacity at the time of the request and whether specialized capabilities matched the patient’s needs.

Below is a receiving-side operational playbook aligned to 42 CFR 489.24(f). Each control outlines implementation steps, evidence to retain, a low-cost method, and the legal anchor.

1) Capacity Snapshot With Time-Stamped “Go/No-Go”

• Implement: Maintain a live “acceptance grid” showing staffed beds by unit, on-call roster, and key equipment (vent availability, Cath lab status). Time-stamp updates each shift and whenever conditions change (e.g., surge, isolation closures).

• Evidence: Printed or exported snapshot with date/time, bed counts, and on-call list; screen captures during the transfer call; change log noting activation of surge plans.

• Low-cost: Use a simple shared spreadsheet with conditional formatting and an auto time-stamp cell; print to PDF at shift handoff.

• Authority: Capacity determinations for accepting transfers under 42 CFR 489.24(f).

2) Two-Minute Acceptance Script for Transfer Center/House Supervisor

• Implement: Script questions: patient age/sex, working diagnosis, current vital threats, treatments given, required capability (e.g., neurosurgery, OB with OR), and estimated time-to-arrival. End with a binary decision tied to the current capacity snapshot.

• Evidence: Transfer call log with the script fields and a recorded “accept” or “lack of capacity” disposition plus reason.

• Low-cost: A one-page script laminated at the transfer desk; EHR smart phrase for the accepting physician note.

• Authority: Timely acceptance is part of the “appropriate transfer” ecosystem; refusal requires defensible lack of capacity under 42 CFR 489.24(f).

3) On-Call Engagement and Escalation Ladder

• Implement: Require the house supervisor to contact the on-call specialist within five minutes when the requested capability is specialty-driven. If no response in ten minutes, escalate to department chair/backup, then medical staff leadership.

• Evidence: Call time stamps, response times, and escalation notes; on-call schedule with signatures acknowledging EMTALA duties.

• Low-cost: A color-coded escalation flowchart and a shared paging group for each specialty.

• Authority: Receiving obligations rely on real-time specialized capability availability (42 CFR 489.24(f)); on-call responsiveness supports capability in fact.

4) Diversion vs Capacity Matrix

• Implement: Define what “diversion” means locally (e.g., EMS bypass due to ED boarding) and list which services remain able to accept transfers. Clarify that diversion of walk-ins does not automatically equal zero capacity for interfacility transfer to ICU or OR.

• Evidence: Diversion policy, incident logs, and crosswalk showing which specialties remained open during each diversion period.

• Low-cost: A single-page matrix kept at charge nurse stations and transfer center.

• Authority: 42 CFR 489.24(f) focuses on actual capacity; diversion status must align with true service availability.

5) Bed-Assignment within Ten Minutes of Acceptance

• Implement: After acceptance, assign a provisional bed (unit/acuity) within ten minutes and notify receiving team lead (e.g., ICU charge).

• Evidence: Bed-assignment time stamp, transport ETA, and handoff acknowledgement.

• Low-cost: Use a shared bed board with a dedicated “incoming transfer” lane and an ETA column.

• Authority: While not verbatim in the regulation, timely execution demonstrates operational capacity consistent with the acceptance duty (42 CFR 489.24(f)).

6) Financial Neutrality Safeguard

• Implement: Lock out any payer/authorization prompts until after bed assignment and clinical handoff begin. Educate staff that acceptance decisions cannot be influenced by insurance or ability to pay.

• Evidence: EHR configuration screenshot, registration workflow diagram, and staff attestations from orientation.

• Low-cost: A registration “pause” order set triggered by “incoming transfer” status.

• Authority: EMTALA duties are payer-blind; acceptance hinges on capability and capacity (42 U.S.C. 1395dd; 42 CFR 489.24).

7) Specialized Capability Index (SCI)

• Implement: Create a concise index of service lines that qualify as specialized capability in your hospital (e.g., “24/7 general surgery with emergent OR within 30 minutes,” “tele-stroke with tPA protocol and transfer to thrombectomy”). Pre-commit default acceptance rules for each.

• Evidence: SCI document reviewed quarterly by medical executive committee; updates recorded.

• Low-cost: Two-page PDF posted on the intranet and printed in the transfer center.

• Authority: Acceptance obligation triggers when your specialized capability matches the patient’s need (42 CFR 489.24(f)).

8) Exception File for Legitimate Lack of Capacity

• Implement: When refusing, complete a brief “exception file” listing the concrete barrier (e.g., no staffed ICU beds, no ventilators, OR closed due to sterile processing failure), who verified it, and when it is projected to resolve.

• Evidence: Exception file with signatures from house supervisor and medical staff leader; attach bed census at refusal time.

• Low-cost: A simple digital form with drop-down reasons and evidence fields.

• Authority: Capacity must be factual and time-specific to support refusal (42 CFR 489.24(f)).

9) Rapid Readiness on Arrival

• Implement: Pre-notify pharmacy, lab, and imaging; prime order sets for common transfer indications (e.g., sepsis, intracranial hemorrhage, STEMI, obstetric hemorrhage, psych hold).

• Evidence: Handoff note, order-set time stamps, first antibiotic time, or door-to-CT metrics.

• Low-cost: Shared quick-order panels and a group-paging macro.

• Authority: Acceptance should be paired with timely stabilizing care upon arrival, consistent with EMTALA’s stabilizing intent.

10) Weekly “Five-Case” Review

• Implement: Review five transfer calls per week across services. Confirm that acceptance/refusal matched the capacity snapshot and that any refusal had a completed exception file.

• Evidence: Minutes with action items; trend graphs for acceptance time and refusal reasons.

• Low-cost: A 20-minute huddle using a standing template.

• Authority: Ongoing monitoring demonstrates a robust EMTALA compliance program supporting 42 CFR 489.24(f).

Wrap-up: These controls compress the time from request to decision, align choices with a defensible capacity record, and ensure your chart tells a coherent EMTALA story.

Case Study

Scenario: A 64-year-old with intracranial hemorrhage needs neurosurgical capability. A critical access hospital calls your transfer center. Your dashboard shows one staffed ICU bed open, neurosurgery on-call, and a staffed OR. ED is on ambulance diversion for general medical patients due to boarding, but ICU and OR are available.

Action: Using the script, the transfer center confirms the need for neurosurgery, logs acceptance within three minutes, and assigns ICU bed 5. Pharmacy preps antihypertensive drips; radiology readies CT. The on-call neurosurgeon is connected with the sending physician and confirms the care plan.

Outcome: Patient arrives within 35 minutes, goes directly to CT, and then to OR. Documentation shows acceptance at 14:03, bed assignment at 14:09, and OR wheels-in at 15:02.

Why it’s defensible: Despite ED diversion, your ICU and OR had capacity and specialized capability, triggering the acceptance duty under 42 CFR 489.24(f). The logged times and exception-free file validate that refusal would have been noncompliant; acceptance was correct and timely.

Wrap-up: These six items build a durable paper trail proving your acceptance decisions were capacity-driven and compliant.

Common Audit Pitfalls to Avoid Under 42 CFR 489.24(f)

Receiving-side compliance often fails in predictable ways. Addressing these pitfalls up front reduces risk and speeds safe patient movement.

• Equating “no ED stretchers” with “no ICU capacity.” Capacity is unit- and service-specific; an ICU bed with staffed nurse and ventilator equals capacity for a neuro or sepsis transfer, even if the ED is crowded. Consequence: Surveyors may cite refusal despite capacity. Reference: 42 CFR 489.24(f).

• Letting payer status color acceptance decisions. Insurance inquiries before saying yes/no are improper. Consequence: Documentation suggests illegal screening for ability to pay. Reference: 42 CFR 489.24; EMTALA’s payer-neutrality principle.

• Slow or absent on-call engagement. If the specialist is nonresponsive, capability in practice may be deemed lacking, and that becomes your problem. Consequence: Findings against the hospital and potential medical staff action. Reference: 42 CFR 489.24(f) (specialized capabilities); interplay with 42 CFR 489.24(j) (on-call).

• Refusing on “anticipated” capacity problems instead of current facts. Predicted admission surges do not erase present capacity. Consequence: Unfounded refusal. Reference: 42 CFR 489.24(f).

• Claiming diversion without service-by-service evidence. EMS diversion is not a blanket shield. Consequence: Citations if ICU/OR were, in fact, open. Reference: 42 CFR 489.24(f).

• No exception file when refusing. Without a contemporaneous record, later “we were full” claims fall apart. Consequence: Adverse survey finding due to lack of evidence. Reference: 42 CFR 489.24(f).

Wrap-up: Avoiding these traps shows your decisions were grounded in actual capacity and specialized capabilities, meeting the regulatory acceptance duty.

Ownership and accountability. The COO (operations), CNO (nursing resources), and ED/House Supervisor (bed control) co-own the acceptance grid. Service chiefs co-own the Specialized Capability Index and on-call responsiveness standards. Medical staff by laws should explicitly reference EMTALA obligations for accepting transfers.

Training cadence. New staff orientation covers the acceptance script, the capacity snapshot, and financial neutrality. Quarterly drills run “mystery calls” to test response times, escalation, and alignment between the snapshot and decisions. Annual competencies include a chart review focused on acceptance timing and documentation.

Metrics that matter. Track median time from call to acceptance decision, proportion of refusals with completed exception files, and acceptance rate by service line. Post trends on a unit dashboard and review in medical executive committee. Use outliers for quick PDSA cycles: adjust staffing flex pools, refine escalation ladders, or correct documentation gaps.

Policy synchronization. Align transfer acceptance policy with on-call, diversion, and surge policies. Ensure policies agree on who can say “no,” under what documented conditions, and what evidence must be preserved. Synchronization prevents mixed signals during surveys.

Receiving hospitals carry a clear duty under 42 CFR 489.24(f) to accept appropriate transfers when they have specialized capabilities and capacity. Compliance comes down to real-time truth: do you have the people, space, and equipment to care for the patient’s emergency condition now. Facilities that simplify the yes/no decision, prove their capacity with time-stamped artifacts, and launch intake immediately after acceptance protect patients and reduce regulatory risk.

Immediate next steps for a small hospital

1. Stand up a live acceptance grid today and time-stamp it every shift; archive PDF snapshots to your compliance folder.

2. Implement the two-minute acceptance script at the transfer center or house supervisor desk and audit five calls weekly.

3. Publish a one-page Specialized Capability Index with default acceptance rules; review quarterly with service chiefs.

4. Configure your EHR to pause registration/insurance prompts until after bed assignment and clinical handoff.

5. Create the exception file template for legitimate capacity refusals, with mandatory attachments (bed census, on-call roster, equipment status).

Recommended compliance tool

A shared “Medicare Plan Interaction” log and policy folder on your existing network or EHR, used to store scripts, training records, and any sponsor correspondence about beneficiary communications. 

Advice:

Before the next open enrollment, walk through your clinic as an auditor would and remove or rewrite anything that could be interpreted as recommending one Part D plan over another.

• eCFR: 42 CFR 489.24 — Special responsibilities of Medicare hospitals in emergency cases
  

• United States Code: 42 U.S.C. 1395dd — Examination and treatment for emergency medical conditions and women in labor
  

• CMS State Operations Manual, Appendix V — Interpretive Guidelines for EMTALA
  

• HHS OIG — Civil Money Penalties Authorities Related to EMTALA
  

• Federal Register — Medicare Program; Clarifying Policies Related to the Responsibility of Medicare-Participating Hospitals in Treating Individuals with Emergency Medical Conditions (EMTALA) (Final Rule)