CurrentHealthfirstPolicy PO-RE-094v2

Avoidable Readmission

Healthfirst's policy governs denial of inpatient acute care hospital claims deemed avoidable readmissions within 30 days of an index discharge and applies to specified lines of business and providers submitting inpatient claims.

Policy Summary

PayerHealthfirst

PolicyAvoidable Readmission

Policy CodePolicy PO-RE-094v2

Change TypeClarified / Revised

Effective DateJan 1, 2019

Next Review Date

Key ActionIf Healthfirst determines the admission is an Avoidable Readmission, the provider will be notified of an administrative denial and must submit medical records from both admissions plus a clinical narrative supporting any exception.

SourceLink

POLICY UPDATE CHANGES

All readmissions within the 30-day period are anchored to the initial index admission and subsequent admissions do not reset or create a new index admission.

The 30-day readmission window is measured from the discharge date of the initial index admission only; admissions outside that window are not considered readmissions.

Relatedness of readmissions is determined based on the same Diagnostic Related Group (DRG) rather than Major Diagnostic Categories (MDC).

30 daysreadmission measurement window

1index admission anchoring

Multiple LOBslines of business covered

N/AApplicable codes

Avoidable Readmission Coverage Criteria

Avoidable Readmission denial criteria and exceptions

Healthfirst will deny any inpatient acute care claim that meets the Avoidable Readmission definition unless an exception applies.

Claim is for an inpatient acute care hospital admission that meets the Avoidable Readmission definition (admission occurring within 30 calendar days of discharge from the initial index admission and related by diagnosis group/DRG).

The readmission is within 30 calendar days from the discharge date of the initial index admission and is anchored to that initial index admission (subsequent admissions do not reset or create a new index admission).

Unless ANY of the following exceptions applies

Patient transferred from out of network (OON) to in network (INN).
Patient transferred to an inpatient rehabilitation facility.

Policy Summary

PayerHealthfirst

PolicyAvoidable Readmission

Policy CodePolicy PO-RE-094v2

Change TypeClarified / Revised

Effective DateJan 1, 2019

Next Review Date

SourceLink

On This Page

Applicable Codes and Timing

Applicable codesmixed

No specific CPT/ICD-10/DRG codes enumerated in this policy; relatedness determined by Diagnostic Related Group (DRG).

Readmission window (inv-03)

Measurement window30 calendar days measured from the discharge date of the initial index admission (anchored to that index discharge)

Anchoring ruleAll readmissions within the 30‑day period are anchored to the same initial index admission; subsequent admissions do not reset or create a new index admission (no rolling readmission logic)

Exclusions by timingAdmissions occurring more than 30 days after the initial index discharge are not considered readmissions and are not subject to denial under this policy

Provider Notification, Documentation, and Recovery Actions

Prior Authorization

Initial administrative denial — provider notification and required documentation

If Healthfirst determines the admission is a Readmission of the index admission, the provider will be notified of an administrative denial. The denial will be upheld unless the provider demonstrates the admission does not meet the Avoidable Readmission criteria. As part of review and reconsideration, submit medical records from both the index and readmission hospitalizations and a clinical narrative (including stabilization at discharge, how initial treatment met clinical needs, and that an adequate discharge plan with services/medication/follow-up was arranged). Also include a letter or summary identifying pages in the records containing information pertinent to the review and any exception criteria being asserted.

Submit complete medical records from both admissions.
Include a letter or summary identifying relevant pages in the records.
Provide a clinical narrative addressing: (a) how initial treatment met clinical needs, (b) how the patient was stabilized before discharge, and (c) documentation that an adequate, timely discharge plan was developed with necessary services, medications, and follow-up.

Denial Risk

Consequences for incomplete records and potential recoupment

Failure to provide complete medical records from the index and readmission hospitalizations may result in an adverse determination during reconsideration. Healthfirst may deny claims, recoup or recover monies previously paid within state-allowed lookback/recovery time frames and per provider contract.

Incomplete records can lead to adverse determination under reconsideration.
Healthfirst may look back within the maximum allowed recovery time per state guidelines or provider contract to identify avoidable readmission claims.
Healthfirst may deny the claim or recoup/recover previously paid amounts for claims within this policy's guidelines.

Key Definitions

Avoidable Readmission definition (inv-06)

DefinitionAn admission to an acute care hospital within 30 days of discharge from the initial index admission for the same, similar and/or related diagnosis group

Relatedness criterionA subsequent admission is considered related to the index admission if it is for the same Diagnostic Related Group (DRG)

Index anchoringSubsequent admissions within 30 days are evaluated against the initial index admission and do not establish a new index admission (eliminates rolling readmissions)

Timing exclusionAdmissions more than 30 days after the initial index discharge are not considered avoidable readmissions under this policy