Reimbursement Policy Inpatient Readmissions
This policy governs Anthem HealthKeepers' reimbursement stance for inpatient unplanned readmissions to the same hospital within 30 days and specifies exclusions and billing expectations; it affects facility inpatient claims for Anthem HealthKeepers Medicaid products in Virginia.
Updated policy language for clarification purposes; clarified planned versus unplanned readmissions; reorganized exclusions to provide clarity.
Inpatient Readmission Coverage Criteria
Inpatient readmission coverage criteria
Denied or recouped when ALL of the following apply unless otherwise required by provider, state, federal, or CMS contracts:
Unplanned readmission up to 30 days from discharge
Similar diagnosis defined as diagnosis codes possessing the same first three digits
ALL of the following
- ONE OR MORE OF: The same or closely related condition or procedure as the prior discharge
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.