CurrentEmblemHealthPolicy RPC2O220022

Hospital Readmission Policy

Governs payment and clinical review rules for inpatient readmissions to the same acute care hospital or hospital system within 30 calendar days, affecting acute care facilities and claims for EmblemHealth/ConnectiCare members across Commercial, Medicare Advantage, and Medicaid lines of business.

Policy Summary

PayerEmblemHealth

PolicyHospital Readmission Policy

Policy CodePolicy RPC2O220022

Change TypeClarified billingreorganized exclusions

Effective DateAug 30, 2022

Next Review Date

Key ActionWhen combining claims for related readmissions, submit a corrected claim using TOB 117 if the initial admission claim was already submitted.

SourceLink

POLICY UPDATE CHANGES

Policy language updated to clarify medical record review; no changes to existing policy criteria.

Updated with clarification of billing instructions.

Reformatted and reorganized policy and clarified obstetric admissions exception; added unavoidable complication exception; LTACH added to exceptions.

30 daysreadmission review time window

All linesapplies to

Combined DRGprocessing

Multiple

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Readmission Coverage and Review Criteria

Primary readmission coverage and processing criteria

Readmissions occurring within 30 calendar days are clinically reviewed and, when related to a preceding admission, are consolidated into a single episode of care for reimbursement; processing differs by business line.

Readmission occurs within 30 calendar days of prior discharge

Readmission to the same acute general short-term hospital or to a hospital within the same hospital system (identified by assigned provider identifier)

Clinical review of medical records to determine whether the readmission is for the same, similar, or related diagnosis as the immediately preceding admission; reviews are performed on a concurrent basis

If related to preceding admission

Commercial: combine multiple DRG hospital claims into one claim; consolidate codes, billed charges and length of stay; reprocess maximum allowable using an industry standard DRG grouper and DRG methodology
Medicare Advantage and Medicaid: subsequent DRG claim will be denied and a corrected claim must be submitted; aligns with CMS practice

Each readmission is reviewed against criteria relative to the immediate preceding admission when multiple readmissions occur

Preventability considerations

Admissions excluded from readmission combining and review measure.

Excluded admissions

Discharge against medical advice (AMA)
Planned readmission as part of a treatment plan for cancer
Planned readmission as part of a treatment plan for transplant services
An elective admission for a staged procedure that follows commonly accepted practices
Obstetrical admission related to delayed delivery

DRG Consolidation and Coding Rules

DRG consolidationmixedCovered

DRG	Diagnosis-Related Group — multiple readmission DRG claims will be combined and reprocessed using an industry standard DRG grouper

Readmission window — numeric

Readmission window (days)30

Related claim handlingRelated services must be combined into a single claim for one episode of care; submit corrected claim using TOB 117 if initial claim already submitted

DRG consolidation timingReadmissions to same hospital within 30 days are combined and processed as a single DRG episode for Commercial plans

Provider Billing, Authorization, and Claim Submission

Note

Follow preauthorization rules and submit corrected claims (TOB 117) when combining readmissions

This policy does not supersede any inpatient recommended or required preauthorization or notification rules that are currently in place. When multiple related inpatient stays meet the criteria to be combined into a single episode of care, providers must submit a corrected claim using Type of Bill (TOB) 117 (Replacement of Prior Claim) if the initial admission claim has already been submitted.

Related services must be combined into a single claim for one episode of care when eligible.
If related services were billed as multiple separate inpatient episodes that meet combining criteria, they may be combined for processing or returned for corrected submission.

Key Definitions

Readmission — definition

DefinitionAn unexpected admission to the same acute care facility or an acute care facility that is part of the same hospital network within 30 calendar days of the previous hospital discharge date

Clinical reviewMedical records will be reviewed to determine if the readmission is related to the preceding admission

ScopeApplies to all EmblemHealth/ConnectiCare lines of business including Commercial, Medicare Advantage, and Medicaid

CMS all-cause readmission — definition

CMS all-cause definitionAn admission to an acute care hospital within 30 days of discharge from the same or another acute care hospital where the cause need not be related to the initial admission

Policy alignmentThis policy takes the CMS all-cause definition into consideration when assessing readmissions