Hospital readmission reimbursement
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This policy governs eternalHealth's reimbursement stance for inpatient hospital readmissions (within a 30-day window) for all products and network and non-network inpatient facilities and applies to all eternalHealth members.
No material clinical or coverage changes in this revision.
Readmission Coverage Criteria and Billing Rules
Readmission coverage criteria and billing rules
eternalHealth will not separately reimburse readmissions determined to be the same, similar, or related within 30 days of discharge unless exclusions, coding, contractual, or regulatory requirements indicate otherwise. Separate reimbursement or exclusions apply when the following criteria are met:
Acceptable reasons for separate reimbursement (Any one of the following)
- Readmission is unrelated to the initial admission
Allows separate reimbursement when clinical review finds no relation to prior admission.
- Readmission is medically necessary and unavoidable due to complications not reasonably preventable
Clinical review determines necessity and unavoidability based on records.
- Readmission required for a planned staged procedure or treatment
Providers must combine with the initial admission and report occurrence span code 74 on the UB-04 when applicable.
- Transfer to another acute care facility to receive care not available at the first facility
Transfers for higher level or specialized care are excluded from readmission denial.
- Readmission for unrelated trauma or a new diagnosis
New, unrelated diagnoses or trauma are eligible for separate reimbursement.
- Readmissions due to patient non-compliance or social determinants beyond provider control
When factors outside provider control cause readmission, separate reimbursement may be allowed.
See coding requirements for same-day claims.
When combined, only one DRG will be reimbursed; submit one bill for covered and leave days.
eternalHealth will not reimburse for events defined by the National Quality Forum/CMS.
Licensed clinical medical review and clinical criteria are used to determine relatedness and preventability.
Administrative recovery or recoupment actions may follow for claims that meet readmission guidelines.
Providers must submit records for both admissions when appealing/disputing a readmission determination; clinical review will evaluate infection/complication, failed surgical intervention, acute decompensation of chronic disease, preventable needs, or premature discharge as potential indicators.
Use the 30-day lookback from date of discharge excluding discharge and admission days.
eternalHealth does not allow payment for the first admission when a same-date readmission for the same/similar diagnosis occurs; readmissions on the same date for symptoms related to the prior stay should be combined.
Claim Coding and Readmission Timing Rules
| Occurrence Span Code 74 | Report planned readmission/leave of absence dates on the UB-04 when combining with initial admission. |
| Condition Code B4 | Report same day readmissions unrelated to initial admission to be eligible for separate reimbursement. |
Appeals, Medical Record Submission, and Operational Steps
Appeal/Dispute — Submit Medical Records for Both Admissions
If you disagree with eternalHealth's readmission determination, you may appeal or dispute the decision by submitting complete medical records for both the initial and subsequent admissions so eternalHealth can perform a clinical review to determine whether the second admission is a readmission of the first.
- Submit medical records for both admissions for review.
- eternalHealth will use licensed clinical medical review and clinical criteria (e.g., infection/complication of care, failed surgical intervention, acute decompensation of chronic disease, premature discharge) to evaluate readmission status.
- eternalHealth may look back within the maximum recovery time allowed by state guidelines or provider contract when identifying readmissions.
Medical Record Review per CMS — Records May Be Requested to Determine Reimbursement
eternalHealth may request and review medical records consistent with CMS guidelines to determine whether a readmission is eligible for separate reimbursement; reimbursement will only be allowed when the readmission is found to be unrelated, medically necessary/unavoidable, planned/staged, a required transfer, due to unrelated trauma/new diagnosis, or caused by factors outside provider control.
- Medical record requests and review follow CMS guidelines.
- Readmission will be reimbursed only if determined to be: unrelated to the initial admission; medically necessary and unavoidable; required for a planned staged procedure; a transfer for services not available at the first facility; for unrelated trauma/new diagnosis; or due to patient factors beyond provider control.
- If readmission is related and preventable, eternalHealth may deny payment or apply a financial penalty (reduced or bundled payment adjustment).
Key Definitions
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