CurrentmhnPolicy CC.PP.501

Payment Policy: 30 Day Readmission

Defines when The Health Plan may deny or recover payment for inpatient hospital readmissions within 30 days of discharge, and describes review, documentation, and appeal processes for hospitals and related hospital systems.

Policy Summary

Payermhn

PolicyPayment Policy: 30 Day Readmission

Policy CodePolicy CC.PP.501

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionHospitals must forward medical records for both the initial admission and the readmission upon The Health Plan's request; failure to provide both records may result in denial of the second claim.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysreadmission window

≤1exclusion: Age

Critical Accessexclusion: Facility type

Pre-/Post-paymentclaim review

Records requireddocumentation

Readmission Denial and Exclusion Criteria

inv-01: Denial criteria for inappropriate/preventable readmissions

Readmissions considered inappropriate or preventable when due to the following:

ALL of the following may indicate an inappropriate/preventable readmission

One or more of
- The readmission was medically unnecessary.
- The readmission resulted from a prior premature discharge from the same hospital or a related hospital.
- The readmission resulted from a failure to have proper and adequate discharge planning.
- The readmission resulted from a failure to have proper coordination between the inpatient and outpatient health care teams.

Policy Summary

Payermhn

PolicyPayment Policy: 30 Day Readmission

Policy CodePolicy CC.PP.501

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

inv-02: Exclusions

Explicit exclusions from 30-day readmission review:

EXCLUDED readmissions include

Transfers from out-of-network to in-network facilities.
Transfers of patients to receive care not available at the first facility.
Readmissions that are planned for repetitive or staged treatments (e.g., cancer chemotherapy or staged surgical procedures).
Readmissions associated with malignancies, burns, or cystic fibrosis.
Admissions to Skilled Nursing Facilities, Long Term Acute Care facilities, and Inpatient Rehabilitation Facilities (SNF, LTAC, and IRF).
Readmissions where the first admission had a discharge status of 'left against medical advice'.
Obstetrical readmissions.
Readmissions ≥ 31 days from the date of discharge from the first admission.
Age ≤ 1.
Critical Access Hospitals.

If a hospital is part of a system (shared hospital agreement or tax identification number), readmission to another hospital in the same system within 30 days will be treated as a readmission to the same hospital and is subject to this policy.

inv-03: Review process and payment recovery actions

Review and payment actions:

Pre-payment review

All hospital claims that qualify as a readmission within 30 days of discharge from the same or a related hospital are subject to clinical review.
Medical records for both the original and subsequent admission(s) will be requested; if records for both admissions are not received, the second claim will be denied.
If records were not received and a denial is issued, the hospital must submit an adjustment or appeal and include medical records for both admissions; submission of records for only one admission will result in denial of the adjustment or appeal.
Clinical information will be reviewed by a qualified clinician to determine if the readmission was inappropriate or preventable; if so, written notification will be sent and payment for the readmission will be denied.

Post-payment (retrospective) review and recovery

The Health Plan may conduct post-payment review if a prepayment review was not conducted; the hospital must forward medical records for all related admissions upon request.
If a readmission is determined to be inappropriate, unnecessary, or preventable after post-payment review, written notification will be sent and the hospital will be requested to refund the applicable payment(s).
If the hospital fails to refund applicable payment(s), The Health Plan may recover payment by offset against future payments unless prohibited by law or contract.

For both pre- and post-payment reviews, clinical determinations are based on the policy guidelines (including evaluation for premature discharge) and are made by qualified clinicians.

Documentation, Submission, and Recovery Procedures

Documentation Required

Pre-payment Clinical Review and Documentation Requirements

All hospital claims that qualify as a readmission within 30 days of a discharge from the same or a related hospital are subject to clinical review. Upon request from The Health Plan, the hospital (and related hospital, if applicable) must forward all medical records and supporting documentation for the initial and subsequent admissions for review. If requested records for both admissions are not received for a claim selected for pre-payment review, the second claim will be denied.

Medical records must include documentation of discharge planning and clinical course for both admissions.
If medical records for both admissions are not provided during pre-payment review, the second claim will be denied.
If a denial is issued due to missing records, submit an adjustment or appeal with complete medical records for both admissions to initiate reconsideration.

Denial Risk

Post-payment Clinical Review and Recovery

The Health Plan may conduct post-payment (retrospective) reviews when a prepayment review was not done. If a post-payment review determines a readmission was clinically related and inappropriate, unnecessary, or preventable, The Health Plan will notify the hospital in writing and request refund of the payment(s). If the hospital fails to refund the applicable payment(s), The Health Plan may recover payment by offset against future payments when not prohibited by law or contract.

Hospitals must forward medical records for all related admissions upon The Health Plan's request for post-payment review.
All clinical information will be reviewed by a qualified clinician to determine if the readmission was inappropriate, unnecessary, or preventable.
Refund requests following a determination of inappropriate readmission may be recovered by offset if refunds are not made.
The review will evaluate the appropriateness of discharge and the quality of the discharge plan as part of determining preventability.

Key Definitions

Clinically Related

DefinitionAn underlying reason for a subsequent admission that is plausibly related to care rendered during or immediately following a prior hospital admission (e.g., surgical wound infection) or from lack of post‑admission follow‑up.

Cause examplesMay result from processes of care during the prior admission or inadequate follow‑up arrangements, not from unrelated traumatic events.

Role in reviewUsed to determine whether a readmission within the specified interval is clinically related and subject to prevention assessment.

Initial Admission

DefinitionAn inpatient admission at an acute, general, or short‑term hospital (or a related hospital) whose discharge date is used to determine whether a subsequent admission occurs within 30 days.

Related hospitalIncludes another hospital in the same hospital system (treated as the same hospital for readmission determination).

PurposeServes as the index hospitalization for calculating the 30‑day readmission window.

Potentially Preventable Readmission (PPR)

DefinitionA clinically related readmission within the specified interval that may have been prevented had adequate care been provided during the initial hospital stay.

Relation to clinical reviewPPRs are the focus of clinical review to determine preventability and possible payment denial or recovery.

ExamplesIncludes readmissions plausibly resulting from prior care (e.g., post‑operative complications) rather than unrelated events.

Readmission

DefinitionAn admission to a hospital occurring within 30 days of the date of discharge from the same hospital or a related hospital; intervening non‑acute facility stays do not affect designation.

30‑day window calculationNeither the day of discharge nor the day of readmission is counted when determining the 30‑day interval.

ExclusionsIntervening admissions to non‑acute care facilities (e.g., skilled nursing facility) are not considered readmissions and do not alter designation.

OpenPayer

Payment Policy: 30 Day Readmission

Readmission Denial and Exclusion Criteria

Readmission Interval and Codes

Documentation, Submission, and Recovery Procedures

Key Definitions