CurrentAspirus ArisePolicy AS23P0002A1

Inpatient Hospital Readmission

Defines Aspirus Health Plan Medicare Advantage payment rules for inpatient hospital readmissions occurring 1–30 days after a prior inpatient stay for enrolled plan members and applies to facilities paid by MS-DRGs.

Policy Summary

PayerAspirus Arise

PolicyInpatient Hospital Readmission

Policy CodePolicy AS23P0002A1

Change TypeAnnual reviewnon‑material updates

Effective DateJan 1, 2023

Next Review Date

Key ActionRespond to post-payment medical record requests within the allotted timeframe to avoid recovery.

SourceLink

POLICY UPDATE CHANGES

Annual review complete. No changes made.

Removed reference to Aspirus Health Plan Elite RX product (term 12/31/2023).

Policy published by Aspirus Health Plan on November 7, 2023.

30 daysreadmission window governed by policy

1-30 daystimeframe for readmission payment guidelines

AS23P0002A1Policy identifier

2025-03-17Last update date

multiplelisted clinical and administrative readmission exclusions

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Inpatient Readmission Coverage Criteria

Applies to enrolled Aspirus Health Plan Medicare Advantage members and governs readmissions occurring 1 through 30 days after a prior inpatient stay for facilities paid by MS‑DRGs.

Policy applies only to enrolled Aspirus Health Plan Medicare Advantage members (enrollee eligibility).

Policy applies to facilities paid based on Medicare Severity Diagnosis Related Groups (MS‑DRGs).

Readmission timeframe

Readmission occurs within 1 through 30 days of a prior inpatient hospital stay.
Readmissions falling outside the 1–30 day window are not governed by this policy.

Inpatient readmission review criteria

Aspirus Health Plan will review inpatient readmissions occurring 1–30 days after a prior stay and excludes specified conditions and circumstances from readmission review.

Readmissions subject to review occur 1 through 30 days from a previous inpatient stay.

Excluded — clinical conditions

Cancer
Psychiatric disease
Hospice
Rehabilitation
Neonatal or obstetrical care
Ophthalmic emergencies

Coding, Claim & Condition Code Guidance

Facility claim guidance

Claim formatFacility claims submitted in 837‑I format; policy applies to facility claims.

CPT/HCPCS placementCPT and/or HCPCS codes should be appended to revenue codes on facility claims as appropriate.

Revenue code guidanceUse revenue codes that best represent the services provided to the patient.

Readmission timeframe

Readmission windowReadmissions occurring 1 through 30 days from a previous inpatient hospital stay are governed by this policy.

Start of windowDay 1 (the day after discharge) counts toward the 30‑day window.

Provider Responsibilities & Billing Actions

Billing Rule

Provider Contractual Requirement & Facility Applicability

Providers must have a current contractual relationship with Aspirus Health Plan to receive payment. This policy applies to both participating and non‑participating facilities — confirm facility participation status against the provider contract before billing. Do not rely solely on this policy when contract language includes different payment terms.

Applies to participating and non‑participating facilities
Provider must be in contractual relationship with Aspirus Health Plan to be eligible for payment

Prior Authorization

Verify Prior Authorization & Notification Requirements

Prior authorization, notification, and threshold requirements are maintained and updated on the plan website. Providers should verify current requirements before scheduling services or submitting claims to avoid delays or denials.

Key Definitions

Clinically Related

DefinitionClinically Related means that the underlying reason for readmission is the same, similar, or related condition to those occurring during a prior hospital admission.

Implication for reviewIf the readmission reason is clinically related to the prior admission, it falls within the scope of readmission review per the policy.

ScopeApplies to inpatient admissions to the same facility following a prior hospital stay.

Readmission

DefinitionReadmission means an inpatient admission to the same facility or hospital that follows a previous hospital stay for the purposes of this policy.

ApplicationUsed to determine whether a subsequent inpatient stay falls within the 1–30 day review window.

Policy Summary

PayerAspirus Arise

PolicyInpatient Hospital Readmission

Policy CodePolicy AS23P0002A1

Change TypeAnnual reviewnon‑material updates

Effective DateJan 1, 2023

Next Review Date

Key ActionRespond to post-payment medical record requests within the allotted timeframe to avoid recovery.

SourceLink

On This Page

Mental health disorder

Transplants and transplant‑related admissions

Excluded — administrative or circumstance‑based

Readmissions to a different facility
Planned readmissions
Patient transfers from one acute care hospital to another
Discharges from the hospital against medical advice

Aspirus Health Plan or its contracted vendor may perform post‑payment reviews and request medical records to determine if multiple hospital stays should be bundled into a single hospital confinement.

If requested, providers must submit medical records within the allotted timeframe; failure to respond may result in recovery of previously paid monies or rebilling as one confinement.

End of windowUp to and including day 30 after the prior inpatient stay.

Check Aspirus Health Plan's website for the most current prior authorization and notification rules
Authorization/notification requirements may change over time

Documentation Required

Post‑payment Medical Record Requests

Aspirus Health Plan or its contracted vendor may request medical records during post‑payment reviews of inpatient admissions and readmissions. Providers must respond within the allotted timeframe. Failure to timely provide requested records may result in recovery of previously paid amounts if claims are reclassified as a single hospital confinement.

Respond to medical record requests within the timeframe specified by Aspirus Health Plan or its vendor
Failure to respond may result in recovery of payments if admissions are determined to be clinically related and billed as one confinement

Facility focusPolicy specifically addresses readmissions to the same facility or hospital.

B4 condition code

CodeB4

MeaningAdmission unrelated to discharge on same day.

Use instructionUse the B4 condition code when submitting claims for an unrelated hospital readmission that occurs on the same day or next day following a previous inpatient stay.

Inpatient hospital readmission exclusions

Clinical exclusionsAdmissions related to cancer, psychiatric disease, hospice, rehabilitation, neonatal or obstetrical care, ophthalmic emergencies, sickle cell crisis, mental health disorder, and transplants or transplant‑related admissions are excluded from readmission review.

Administrative exclusionsReadmissions to a different facility, planned readmissions, patient transfers from one acute care hospital to another, and discharges against medical advice are excluded.

Scope of exclusionsThese exclusions remove specified conditions and circumstances from inpatient readmission review under this policy.