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.
Same-day readmissions that are unrelated to the initial admission must be reported with Condition Code B4 on the UB-04 to be eligible for separate reimbursement
See coding requirements for same-day claims.
Planned readmissions or leaves of absence within 30 days must be combined with the initial admission and reported on the same UB-04 with Occurrence Span Code 74 (report dates leave began and ended)
When combined, only one DRG will be reimbursed; submit one bill for covered and leave days.
Admissions for covered transplant services during the global case rate period are excluded from this readmission policy (handled under transplant global rate)
Admissions to a substance abuse unit or inpatient rehabilitation unit are excluded from this readmission policy
Readmission following discharge against medical advice is excluded from readmission denial review
Readmissions resulting from Never Events or Severe Reportable Events will not be reimbursed
eternalHealth will not reimburse for events defined by the National Quality Forum/CMS.
If readmission is determined to be related and preventable, eternalHealth may deny payment in full or apply a financial penalty (reduced payment or bundled payment adjustment)
Licensed clinical medical review and clinical criteria are used to determine relatedness and preventability.
eternalHealth may look back within the maximum allowed recovery time per state guidelines or specific provider contract to identify readmissions
Administrative recovery or recoupment actions may follow for claims that meet readmission guidelines.
Medical records may be requested and reviewed consistent with CMS guidelines to determine reimbursement eligibility
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.
When calculating the 30-day readmission window, neither the day of discharge nor the day of admission is counted; intervening non-acute admissions do not affect readmission designation
Use the 30-day lookback from date of discharge excluding discharge and admission days.
Readmission to the same hospital for the same, similar, or related condition on the same date of service is considered a continuation of the initial treatment and is not separately payable
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.