CurrentmhnPolicy CC.PP.501

Payment Policy: 30 Day Readmission

Defines when The Health Plan may deny or recover payment for hospital readmissions occurring within 30 days of discharge for the same or related hospitals; applies to individual hospitals and hospitals within the same system.

Policy Summary

Payermhn

PolicyPayment Policy: 30 Day Readmission

Policy CodePolicy CC.PP.501

Change TypeNo material change

Effective Date

Next Review Date

Key ActionHospitals must forward medical records and supporting documentation for initial and subsequent admissions upon 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

Age ≤1excluded: Age ≤1

Critical Accessexcluded: CAH

Clinician reviewreview standard

Medical recordsrecords required

Readmission Determination and Exclusions

Readmission determination and exclusions

Readmissions will be considered inappropriate or preventable under the following circumstances and are subject to denial if clinically determined:

ALL of the following

ONE of
- Medically unnecessary readmission
- Readmission resulting from a prior premature discharge from the same hospital or a related hospital
- Readmission resulting from failure to have proper and adequate discharge planning
- Readmission resulting from 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 change

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.

Clinical review process

Pre-payment review: all hospital claims qualifying as a 30-day readmission are subject to clinical review by a qualified clinician
For claims selected for clinical review, medical records for both the original and subsequent admissions will be requested; if both records are not received the second claim will be denied
If denied for missing records, the hospital must submit an adjustment or appeal and provide both admissions' records to initiate clinical review; submission of records for only one admission will result in denial of the adjustment or appeal
If clinical review determines the readmission was inappropriate, unnecessary, or preventable, written notification will be sent to the hospital and payment for the readmission will be denied

Exclusions (any of the following)

Transfers from out-of-network to in-network facilities
Transfers of patients to receive care not available at the first facility
Planned readmissions for repetitive or staged treatments (e.g., cancer chemotherapy, staged surgical procedures)
Readmissions associated with malignancies, burns, or cystic fibrosis
Admissions to Skilled Nursing Facilities (SNF), Long Term Acute Care facilities (LTAC), and Inpatient Rehabilitation Facilities (IRF)
Readmissions where the first admission had a discharge status of 'left against medical advice'
Obstetrical readmissions
Readmissions occurring ≥ 31 days from the date of discharge from the first admission (i.e., outside the 30-day window)
Patients age ≤ 1
Critical Access Hospitals

Readmission Window and References

External referencesmixed

No codes listed

inv-03: Readmission window — 30 days; day of discharge and day of admission not counted

Readmission windowReadmissions occurring within 30 days of the date of discharge from the same hospital or a related hospital; for calculating the 30-day window, neither the day of discharge nor the day of admission is counted.

Exclusion — beyond windowReadmissions ≥ 31 days from the date of discharge are excluded from 30-day review.

Intervening non-acute admissionsIntervening admissions to non-acute care facilities (e.g., skilled nursing facility) are not considered readmissions and do not affect designation.

Documentation, Submission, and Denial Actions

Documentation Required

Provide complete medical records on request or risk denial

Upon request from The Health Plan, a hospital (or related hospital) must forward all medical records and supporting documentation of the initial admission and readmission to The Health Plan. Failure to provide medical records for both the original and subsequent admissions when requested will result in denial of the second claim; if records are missing and a denial is issued, the hospital must submit an adjustment or appeal with both admissions' records to initiate clinical review.

Hospitals must forward (and, if applicable, arrange for a related hospital to forward) all medical records and supporting documentation of the initial admission and readmission upon request. [[source]]
If medical records for both the original and subsequent admission are not received for a claim selected for clinical review, the second claim will be denied. [[source]]
If denied for missing records, the hospital must submit an adjustment request or appeal and include records for both admissions; submission of records for only one admission will result in denial of the adjustment or appeal. [[source]]

Denial Risk

Denial, refund, and recovery for inappropriate readmissions

If a readmission is determined by clinical review to be inappropriate, unnecessary, or preventable, The Health Plan will deny payment prepayment or request refund and recover payments post-payment; failure to refund may lead to recovery by offset against future payments unless prohibited by law or contract.

Pre-payment: written notification will be sent and payment for the readmission will be denied if clinically determined inappropriate. [[source]]
Post-payment: The Health Plan will request refund of applicable payments and may recover by offset against future payments if the hospital does not refund. [[source]]

Key Definitions

inv-06: Clinically Related — definition of clinically related readmission

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

Scope — cause examplesMay result from the process of care and treatment during the prior admission or from inadequate post‑discharge follow‑up, not from unrelated events occurring after discharge.

Use in reviewClinically related determinations guide denial decisions for readmissions deemed inappropriate or preventable under clinical review methodology.

inv-07: Initial Admission — definition of initial admission

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

Related hospital conceptIf hospitals share the same hospital agreement or tax identification number, a readmission to another hospital in the same system is treated as a readmission to the same hospital.

Role in calculationsThe initial admission's date of discharge establishes the start of the 30‑day readmission window.

inv-08: Potentially Preventable Readmission (PPR) — definition and scope

DefinitionA potentially preventable readmission (PPR) is a readmission within a specified time interval that is clinically related to the initial admission and may have been prevented had adequate care been provided during the initial hospital stay.

Relationship to clinical reviewPPR determinations are made by analyzing the initial stay for premature discharge, incomplete or substandard treatment, inadequate discharge planning, or poor coordination between inpatient and outpatient teams.

Policy consequenceIf a readmission is determined to be potentially preventable, The Health Plan may deny payment or request recovery according to the policy's pre‑ and post‑payment review processes.

inv-09: Readmission — definition referencing 30-day window and related-hospital concept

DefinitionAn admission to a hospital occurring within 30 days of the date of discharge from the same hospital or a related hospital; for the 30‑day calculation, neither the day of discharge nor the day of admission is counted.

Non‑acute admissionsIntervening admissions to non‑acute care facilities (e.g., skilled nursing facilities) are not considered readmissions and do not affect designation.

Systemwide readmissionsReadmissions to another hospital within the same hospital system or sharing the same TIN during the same 30‑day period are treated as readmissions to the same hospital and subject to this policy.