CurrentMolina HealthcarePolicy N/A

Hospital readmission reimbursement policy

Governs Molina Healthcare's reimbursement rules for hospital readmissions (repeat, not separately reimbursable, potentially preventable, planned/LOA) and instructs facilities on combined claim submission and denial practices for affected members and providers.

Policy Summary

PayerMolina Healthcare

PolicyHospital readmission reimbursement policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionWhen a repeat or related readmission occurs, resubmit a single combined corrected claim with total length of stay, combined billed charges, and the DRG from the initial admission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4readmission categories defined

24 hourstypical repeat timeframe

single DRGsingle DRG payment

initial pays bothanchor admission covers both

Readmission Coverage Criteria

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Readmission coverage criteria

Molina's stance and actions by readmission category

Repeat readmissions within state/federal specified timeframe (typically 24 hours) are treated as a single stay.

ALL of the following

Molina will extend the authorization from the initial admission and treat the combined encounters as a single stay.
Provider must submit a combined, corrected claim that includes the total length of stay, combined billed charges for both admissions, and the appropriate DRG from the first (initial) admission.
Molina will deny the subsequent admission claim for a separate DRG payment.

Not separately reimbursable readmissions (readmissions related to the same, similar, or related condition within the state-specified timeframe) are denied as separate DRG payments.

ALL of the following

Facility must resubmit a single, combined, corrected claim including total length of stay, combined billed charges for both admissions, and the appropriate DRG corresponding to the initial admission.
Molina will deny the claim for the subsequent readmission as a separate DRG payment.

Potentially preventable readmissions (related to the initial admission due to premature/inadequate discharge, transition failures, acute complication related to initial care, or inappropriate transfer) will be denied as separate DRG payments.

ALL of the following

Molina will deny the authorization request for the readmission.
Molina will deny the subsequent admission claim for a separate DRG payment because payment for the initial (anchor) admission is considered full payment.
Note: A readmission may be medically necessary yet still be deemed preventable and subject to clinical preventable readmission review.

Planned and Leave of Absence (LOA) readmissions for scheduled non-acute procedures are considered part of the initial episode and are not separately reimbursable.

ALL of the following

Facility must resubmit a single combined, corrected claim including correct revenue/value/occurrence span codes, a combined length of stay (including zero-charge leave days when applicable), and combined billed charges for both admissions.
Molina will deny the subsequent readmission claim for a separate DRG payment.

All categories are subject to state/federal specified time limits for readmission determination.

State or Federal regulations and member benefit plans supersede this policy where applicable; timeframes may be state-specific (refer to State Specific Readmission grid).

Billing, Claims Resubmission, and Authorization Actions

Billing Rule

Repeat readmission billing/authorization — facility must submit combined corrected claim

Repeat readmissions happen when a patient is discharged and readmitted to the same or affiliated hospital within a specified time limit (typically 24 hours or as required by State/Federal regulations). Molina Healthcare will extend the authorization from the initial admission as a single stay. The facility must submit a combined, corrected claim that includes the total length of stay, the combined billed charges for both admissions, and the appropriate DRG based on the circumstances of the initial admission. Molina will deny the subsequent admission claim for a separate DRG payment.

Submit one combined corrected claim including: total length of stay; combined billed charges for both admissions; appropriate DRG from the initial admission circumstances.
Authorization from the initial admission will be extended to cover the combined stay when applicable.
Molina will deny separate payment for the subsequent admission.

Billing Rule

Not separately reimbursable readmission billing — facility must resubmit a single combined corrected claim

Not separately reimbursable readmissions occur when the readmission is for the same, similar, or related condition as the initial admission and falls within the State/Federal time limits. In these cases Molina Healthcare will deny the subsequent readmission claim as a separate DRG payment. The facility must resubmit a single combined, corrected claim that includes the total length of stay, the combined billed charges for both admissions, and the appropriate DRG corresponding to the initial admission.

Resubmit one combined corrected claim including: total length of stay; combined billed charges for both admissions; appropriate DRG corresponding to the initial (anchor) admission.
Refer to the State Specific Readmission grid for applicable time limits.

Billing Rule

Planned/LOA readmission billing requirements — facility must resubmit a single combined corrected claim with correct revenue/value/occurrence elements

Planned and/or Leave of Absence (LOA) readmissions are scheduled, non-acute readmissions within State/Federal time limits (see State Specific Readmission grid). Molina Healthcare will deny the subsequent readmission claim for a separate DRG payment. The facility must resubmit a single combined, corrected claim containing the required LOA billing elements and combined stay information.

Include correct revenue, value, and occurrence span codes required for LOA billing.
Include combined length of stay (counting zero-charge leave days when applicable) and combined billed charges for both admissions.
Examples of planned/LOA readmissions: delayed scheduling of surgery (team unavailable or pending pre-op clearance), planned bilateral or staged procedures, or planned surgical interventions if conservative therapy fails.
Not considered planned/LOA: obstetric delivery; routine chemotherapy, transfusions, dialysis, or similar repetitive treatments; transplant surgery.

Key Definitions

inv-07: Readmission — definition entry

TermReadmission

DefinitionA subsequent admission to a hospital within a predetermined time limit following discharge from the same or an affiliated hospital; readmission to another hospital in the same system or with the same TIN is treated as a readmission to the same hospital for policy purposes.

Policy implicationMolina reviews readmissions to determine category (Repeat, Potentially Preventable, Combined Payment Methodology, Planned) which affects reimbursement treatment.

inv-08: Potentially preventable readmission — definition entry

TermPotentially preventable readmission

DefinitionA readmission to the same or affiliated hospital within the state/federal mandated timeframe for conditions that are the same, similar, or related to the initial admission and attributable to premature/inadequate discharge, care transition failures, acute complications related to initial care, or inappropriate transfer to a lower level of care.

Payment impactMolina will deny the authorization request and deny the subsequent admission claim for a separate DRG payment because the initial (anchor) admission payment is considered full payment.

inv-09: Planned/LOA readmission — definition entry

TermPlanned/LOA readmission

DefinitionA scheduled non-acute readmission to the same or affiliated hospital within the state/federal specified timeframe for a planned procedure or leave-of-absence (LOA); excludes obstetric delivery and repetitive treatments like chemotherapy, dialysis, transfusions, and transplants.

Billing requirementFacility must resubmit a single combined corrected claim with correct revenue/value/occurrence span codes, combined length of stay (including zero-charge LOA days when applicable), and combined billed charges of both admissions.

OpenPayer

Hospital readmission reimbursement policy

Readmission Coverage Criteria

Billing, Claims Resubmission, and Authorization Actions

Coding Guidance and Disclaimers

Key Definitions