Currentmclaren health planPolicy N/A

Readmission

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This document defines McLaren Health Plan's definitions and payment rules for hospital readmissions and transfers and explains submission and preauthorization responsibilities for hospitals across all lines of business.

Policy Summary

Payermclaren health plan

PolicyReadmission

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionThe transferring hospital must obtain preauthorization from MHP for medically necessary transfers when required care is not available at the transferring hospital.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15 dayswindow defining a readmission

2claims for unrelated same-hospital readmissions

≥ $0minimum payment after reduction

requiredtransfers requiring preauth

Readmission and Transfer Payment Criteria

Submission and Coding Rules

readmission submission rulesmixed

No codes listed

Readmission window (threshold)

Readmission window15 days

Related vs unrelated handlingPayment and submission rules vary depending on whether the readmission is related or unrelated and whether it is to the same or a different hospital

Same-hospital unrelated readmissionSubmit two separate claims; the first admission claim must be submitted and paid before submitting the second

Transfer Authorization and Provider Responsibilities

Prior Authorization

Transferring hospital must obtain MHP preauthorization for medically necessary transfers

Authorization for a transfer is granted only if the transfer is medically necessary and the care/treatment is not available at the transferring Hospital. The transferring hospital is responsible to obtain preauthorization from MHP; transfers for convenience are not considered. Failure to obtain required preauthorization may result in payment adjustment through MHP's recovery process.

Transferring hospital must obtain preauthorization from MHP when required.
Preauthorization is required only when the transfer is medically necessary and required care/treatment is not available at the transferring hospital.
Transfers for convenience do not qualify for authorization.
Non-compliance may lead to payment recovery by MHP.

Key Definitions

Readmission — definition and related billing rules

DefinitionAny admission within 15 days of a previous discharge, whether to the same or a different hospital.

Same hospital - unrelatedHospital must submit two separate claims; first admission claim must be submitted and paid before the second claim is submitted.

Same hospital - relatedMHP considers the admission and related readmission one episode of care; related admissions must be combined on a single claim for payment.

Different hospital - relatedMHP reduces the first hospital's payment by the amount of the second hospital's payment but never less than $0.

Policy Summary

Payermclaren health plan

PolicyReadmission

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionThe transferring hospital must obtain preauthorization from MHP for medically necessary transfers when required care is not available at the transferring hospital.

SourceLink

On This Page

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Currentmclaren health planPolicy N/A

Readmission

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Sign up for all mclaren health plan policy alerts

Know when mclaren health plan releases new policies or updates existing guidance.

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Policy Summary

Payermclaren health plan

PolicyReadmission

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionThe transferring hospital must obtain preauthorization from MHP for medically necessary transfers when required care is not available at the transferring hospital.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15 dayswindow defining a readmission

2claims for unrelated same-hospital readmissions

≥ $0minimum payment after reduction

requiredtransfers requiring preauth

Readmission and Transfer Payment Criteria

Submission and Coding Rules

readmission submission rulesmixed

No codes listed

Readmission window (threshold)

Readmission window15 days

Related vs unrelated handlingPayment and submission rules vary depending on whether the readmission is related or unrelated and whether it is to the same or a different hospital

Same-hospital unrelated readmissionSubmit two separate claims; the first admission claim must be submitted and paid before submitting the second

Transfer Authorization and Provider Responsibilities

Prior Authorization

Transferring hospital must obtain MHP preauthorization for medically necessary transfers

Transferring hospital must obtain preauthorization from MHP when required.
Preauthorization is required only when the transfer is medically necessary and required care/treatment is not available at the transferring hospital.
Transfers for convenience do not qualify for authorization.
Non-compliance may lead to payment recovery by MHP.

Key Definitions

Readmission — definition and related billing rules

DefinitionAny admission within 15 days of a previous discharge, whether to the same or a different hospital.

Same hospital - unrelatedHospital must submit two separate claims; first admission claim must be submitted and paid before the second claim is submitted.

Same hospital - relatedMHP considers the admission and related readmission one episode of care; related admissions must be combined on a single claim for payment.

Different hospital - relatedMHP reduces the first hospital's payment by the amount of the second hospital's payment but never less than $0.

Policy Summary

Payermclaren health plan

PolicyReadmission

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionThe transferring hospital must obtain preauthorization from MHP for medically necessary transfers when required care is not available at the transferring hospital.

SourceLink

On This Page