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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyAmerigroup Inpatient Readmissions Policy Update | …
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    CurrentAmerigroupPolicy G-13002

    Inpatient Readmissions

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    Defines the health plan's reimbursement policy for unplanned inpatient readmissions to the same hospital for the same, similar, or related condition and who is affected (facility inpatient providers reimbursed under DRG methodology).

    Policy Summary
    PayerAmerigroup
    PolicyInpatient Readmissions
    Policy CodePolicy G-13002
    Change TypeClarification (non-material)
    Effective Date03/25/2025
    Last ReviewMar 25, 2025
    Next Review DateN/A
    Key ActionSubmit both admissions on a single claim when readmission occurs on the same date of service or is a continuation of initial treatment; use proper billing and submission guidelines and support services with documentation.
    SourceLink
    POLICY UPDATE CHANGES

    Updated policy language for clarification purposes; clarified planned versus unplanned readmissions; reorganized exclusions to provide clarity.

    3 daystime window
    DRGreimbursement method

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    30 daysLOA aggregation
    Exclusions listexclusions

    Readmission Coverage and Reimbursement Criteria

    Readmission reimbursement criteria

    The plan does not separately reimburse unplanned inpatient readmissions to the same hospital for the same, similar, or related condition unless otherwise required by contract.

    Unplanned readmission identified within 3 days of discharge for the same or related condition.
    Clinical coding review and/or licensed clinical medical review determines the subsequent admission is for one of: the same or closely related condition/procedure; an infection or complication of care; failed surgical intervention; acute decompensation of a coexisting chronic disease; a need reasonably preventable by appropriate prior care or follow-up; or an issue caused by premature discharge from the same facility.

    Plan-level actions

    • When criteria above are met, the health plan may deny the claim or recoup/recover previously paid monies.
    • Readmissions occurring on the same date of service for the same, similar, or related condition are considered continuation of initial treatment; providers must submit both admissions on a single claim.

    Exclusions (not subject to readmission denial under this policy)

    • Admissions for medical treatment of cancer, neonatal/newborn, obstetrical deliveries, behavioral health, or rehabilitation care.
    • Sickle cell anemia, transplants, transfers from one acute care hospital to another, or members discharged against medical advice.
    • Planned readmissions and leave of absence readmissions (see aggregation rules: planned/LOA readmissions within 30 days are considered one admission and reimbursed as a single DRG with a single bill).
    Policy applies to facilities reimbursed under DRG methodology; contractual, state, federal, or CMS requirements may override this policy.

    Coding and Time Window Rules

    Coding requirementsmixed
    Standard correct coding applies; use CPT, HCPCS, and/or revenue codes supported by medical record.
    Readmission time window (inv-03)
    Readmission time windowUnplanned readmissions identified when they occur up to 3 days from discharge (≤3 days).
    Condition requirementReadmission must be for the same, similar, or related condition to be considered under this window.
    Determination methodClinical coding criteria and/or licensed clinical medical review used to determine relatedness and applicability of the time window.

    Provider Billing, Claims Submission, and Denial Risk

    Billing Rule

    Billing and claim submission for unplanned readmissions

    The health plan will deny, recoup, or recover payment for claims identified as unplanned readmissions to the same hospital for the same, similar, or related condition; providers must follow proper billing and submission guidelines and ensure services meet authorization and medical necessity. If a readmission occurs on the same date of service or is a continuation of the initial treatment, submit both admissions on a single claim.

    • Unplanned readmission identified as up to three days from discharge may be denied or recouped.
    • Readmissions on the same date of service for the same, similar, or related condition are considered continuation of the initial admission — submit both admissions on a single claim.
    • Use industry-standard CPT, HCPCS, and/or revenue codes supported by the medical record; failure to follow coding/billing guidelines may result in claim rejection, denial, or recovery.

    Key Definitions

    Leave of Absence (inv-05)
    DefinitionLeave of Absence: an interim period when readmission is expected, and the patient does not require a hospital level of care.
    Aggregation ruleWhen a member is readmitted within 30 days as part of a planned readmission and/or placed on a leave of absence, the admissions are considered one admission and only one DRG will be reimbursed.
    Billing instructionProviders must submit one bill for covered days and days of leave when the patient is ultimately discharged.
    Planned Readmission (inv-06)
    DefinitionPlanned Readmission: acute readmission for a scheduled procedure.
    Treatment with LOAPlanned readmissions occurring within 30 days may be aggregated with the original admission and reimbursed as a single DRG.

    Acute Hospital Admission Criteria

    Acute hospital — admission criteria

    Admission treatment and billing guidance for acute hospital inpatient admissions.

    When readmission occurs on the same date of service or is a continuation of the initial treatment, treat it as part of the original admission and submit both episodes on a single claim (single DRG where applicable).

    Acute Hospital Continued Stay Criteria

    Acute hospital — continued stay criteria

    Continued-stay handling when leave of absence or planned readmission occurs.

    If a member is readmitted within 30 days as part of a planned readmission or following a leave of absence, treat the admissions as one admission; reimburse a single DRG and require the provider to submit one bill for covered days and leave days when the patient is ultimately discharged.

    Acute Hospital Discharge Criteria

    Readmissions that occur on the same date of service for the same, similar, or related condition are considered a continuation of the initial treatment and part of the original admission. In these cases, providers should submit both admissions on a single claim rather than separate claims. The plan may deny or recoup payment for unplanned readmissions identified within ≤3 days of discharge when the subsequent admission is for the same or related condition, based on clinical coding review or licensed medical review determining issues such as infection, complication of care, failed surgical intervention, acute decompensation of chronic disease, preventable need, or premature discharge.

    Aggregation Periods and Day Limits

    Acute hospital day limits (inv-11)
    Aggregation periodPlanned readmission and leave-of-absence admissions are aggregated over a 30-day period for reimbursement purposes.
    Reimbursement effectWhen aggregated, the admissions are treated as one admission and only one DRG will be reimbursed.
    ScopeThis aggregation rule applies to facilities reimbursed under a DRG methodology.
    Policy Summary
    PayerAmerigroup
    PolicyInpatient Readmissions
    Policy CodePolicy G-13002
    Change TypeClarification (non-material)
    Effective Date03/25/2025
    Last ReviewMar 25, 2025
    Next Review DateN/A
    Key ActionSubmit both admissions on a single claim when readmission occurs on the same date of service or is a continuation of initial treatment; use proper billing and submission guidelines and support services with documentation.
    SourceLink
    On This Page
    Readmission Coverage and Reimbursement CriteriaCoding and Time Window RulesProvider Billing, Claims Submission, and Denial RiskKey DefinitionsAcute Hospital Admission CriteriaAcute Hospital Continued Stay CriteriaAcute Hospital Discharge CriteriaAggregation Periods and Day Limits
    Provider actionSubmit one bill for covered days and days of leave when the patient is ultimately discharged.
    Same Hospital System (inv-07)
    DefinitionSame Hospital System: two or more hospitals owned, leased, sponsored, or contract managed by a central organization.
    ImplicationPolicy applies to readmissions to the same hospital; hospital system ownership/management may be considered when identifying same facility relationships.