CurrentAnthemPolicy G-13001

Reimbursement Policy Inpatient Readmissions

Defines Anthem New York Medicaid reimbursement rules for inpatient readmissions, including when separate payment is disallowed and applicable exclusions; applies to facilities reimbursed under DRG methodology and affects inpatient hospital claims for NY Medicaid members.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Inpatient Readmissions

Policy CodePolicy G-13001

Change TypeClarification / Non-material edits

Effective DateMar 25, 2025

Next Review Date

Key ActionDo not separately bill for unplanned readmissions within 14 days for the same, similar, or related condition; submit same-day readmissions on a single claim.

SourceLink

POLICY UPDATE CHANGES

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

Planned readmission/LOA language added; definition section updated to include LOA and planned readmission; related policy section updated.

14 daysunplanned readmission lookback period

30 daysplanned readmission/leave of absence aggregation period

G-13001policy identifier

NYjurisdiction

Inpatient Readmission Coverage Criteria

Inpatient readmission coverage criteria

The health plan does not allow separate reimbursement for unplanned readmissions that meet the clinical and timeframe criteria below; planned readmissions and leaves of absence are handled separately.

General disallowance: No separate reimbursement for claims identified as an unplanned readmission to the same or different hospital within the same hospital system for the same, similar, or related condition unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Timeframe: Unplanned readmission up to 14 days from discharge is considered for disallowance; readmissions occurring on the same date of service are considered a continuation of the initial admission and should be submitted on a single claim.

ALL of the following

The same or closely related condition or procedure as the prior discharge.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Inpatient Readmissions

Policy CodePolicy G-13001

Change TypeClarification / Non-material edits

Effective DateMar 25, 2025

Next Review Date

Key ActionDo not separately bill for unplanned readmissions within 14 days for the same, similar, or related condition; submit same-day readmissions on a single claim.

SourceLink

On This Page

Exclusions (these readmissions are not subject to the disallowance)

Readmissions for a major or metastatic malignancy.
Readmissions for multiple trauma treatment.
Readmissions for burns treatment.
Readmissions for infants less than 12 months of age at the time of admission.
Readmission for skilled nursing (SNF).
Readmission for long-term acute care (LTAC).
Sickle cell anemia.
Readmissions for neonatal treatment.
Readmissions for obstetrical treatment.
Planned readmissions.
Patient discharged from the hospital against medical advice.
Patient transfers from one acute care hospital to another.

Coding and Temporal Thresholds

General coding guidancemixed

Standard correct coding applies

Temporal thresholds

Unplanned readmission lookback periodUnplanned readmissions are reviewed up to 14 days from discharge for separate reimbursement disallowance

Planned readmission/LOA aggregation periodReadmissions that are part of a planned readmission or leave of absence are aggregated within a 30-day period and treated as one admission for reimbursement

Same‑day readmissionsReadmissions occurring on the same date of service are considered continuation of the initial admission and should be submitted on a single claim

Provider Billing Rules and Actions

Billing Rule

Readmission billing rule

The health plan does not allow separate reimbursement for claims identified as an unplanned readmission to the same or different hospital within the same hospital system for the same, similar, or related condition unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. Unplanned readmissions occurring up to 14 days from discharge for the same or closely related condition or procedure may be identified by clinical coding criteria and/or licensed clinical medical review. Examples include infection or other complication of care, failed surgical intervention, acute decompensation of a coexisting chronic disease, needs that could have been reasonably prevented by appropriate prior care, or issues caused by a premature discharge. Readmissions on the same day (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; providers should submit both admissions on a single claim.

Unplanned readmission up to 14 days from discharge
Same or closely related condition or procedure
Clinical review used to determine relatedness (infection, complication, failed surgery, acute decompensation, preventable need, premature discharge)
Same-day readmissions treated as continuation of original admission — submit as single claim

Billing Rule

Planned readmission / Leave of Absence billing

When a member is readmitted within 30 days as part of a planned readmission and/or placed on a leave of absence (LOA), the admissions are considered one admission and only one DRG will be reimbursed. Providers must submit one bill that includes covered days and days of leave when the patient is ultimately discharged. This requirement applies to facilities reimbursed for inpatient services by a DRG methodology. If an exception is required by payer contract, state, federal, or CMS requirements, follow those specific submission instructions.

Readmission within 30 days that is planned or part of an LOA = single admission for billing
Reimburse one DRG for the entire episode (covered days + leave days)
Providers must submit one bill when patient is ultimately discharged
Applies to facilities reimbursed under DRG methodology
Follow applicable contract/state/federal/CMS exceptions and submission instructions

Denial Risk

Denial / recoupment risk

The health plan reserves the right to deny claims or recoup and/or recover monies previously paid for claims that fall within this readmission policy. Providers should ensure documentation and coding support the clinical relationship (or planned status) between admissions to avoid denial or recoupment.

Plan may deny or recoup payments for unplanned readmissions meeting policy criteria
Ensure clinical documentation and coding justify separate admission when applicable
Same-day readmissions submitted separately may be denied — treat as continuation of original admission

Definitions

Leave of Absence

DefinitionLeave of Absence: an interim period when readmission is expected and the patient does not require a hospital level of care

Reimbursement treatmentWhen a readmission occurs within 30 days as part of a leave of absence, admissions are considered one 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

DefinitionPlanned Readmission: an acute readmission for a scheduled procedure

Timeframe and handlingIf the planned readmission occurs within 30 days, it is treated as part of the same admission for reimbursement purposes (one DRG) when documented as planned

Clinical determinationClinical coding and review determine relatedness to prior discharge when assessing readmissions for exclusion from disallowance

Same Hospital System

DefinitionSame Hospital System: two or more hospitals owned, leased, sponsored, or contract managed by a central organization

ApplicabilityPolicy applies to readmissions to the same or different hospital within the same hospital system for the same, similar, or related condition

Billing implicationUnplanned readmissions within the same hospital system may be disallowed for separate reimbursement per policy criteria