CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Unplanned Hospital Readmission Reimbursement

Governance of reviews and reimbursement denial for unplanned hospital readmissions occurring within 30 calendar days of a prior discharge for Neighborhood Health Plan of Rhode Island members across all lines of business; affects contracted and non-contracted facilities and providers submitting claims.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUnplanned Hospital Readmission Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionFacility may request a reevaluation of a payment decision within 60 days by submitting a Readmission Reevaluation Request form to HRreevaluations@nhpri.org.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysreadmission window for review

60 daystimeframe to request reevaluation

All linesapplicable lines of business

Not reimbursedrelated readmissions

Readmission Review and Coverage Determination

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Readmission review, denial, and exclusions

NHPRI will review medical records to determine if an unplanned readmission within 30 days is clinically related to the prior admission. If related, the readmission will not be reimbursed. The policy also specifies exclusions where readmissions are not subject to this review.

Applies to unplanned readmissions occurring within 30 calendar days of a prior discharge

Members are not liable for claims denied as a readmission

If medical record review determines the readmission is clinically related to the prior admission, the readmission will not be reimbursed

Related if any of the following are met:

Continuation or recurrence of the previous admission (same, similar, or related condition)
Medical complication related to care during the previous admission (e.g., discharged with urinary catheter and readmitted for urinary tract infection)
Unplanned readmission for a surgical procedure to address continuation or recurrence of the problem that caused the previous admission (e.g., appendectomy following previous admission for abdominal pain and fever)
Unplanned readmission for a surgical procedure to address a complication resulting from the previous admission (e.g., drainage of a post-operative wound abscess following admission for bowel resection)

Note: Medical record review is to determine if the admission is related to the prior admission and is not an assessment of medical necessity or appropriateness of the setting

Exclusions (readmissions excluded from review)

Planned readmissions for repetitive treatments such as cancer chemotherapy, transfusions for chronic anemia, or other similar repetitive treatments or scheduled elective surgery
Readmissions due to malignancies limited to patients actively receiving chemotherapy, burns, or cystic fibrosis
Readmissions due to organ or bone marrow transplants
Obstetrical admissions
Readmissions with a documented discharge status of left against medical advice
Readmissions greater than 30 calendar days from the last discharge

Providers must submit medical records upon request to support review; determination focuses on clinical relatedness to prior admission

Provider Responsibilities and Appeals

Prior Authorization

Preauthorization and Contract Rules

Providers must verify member eligibility, coverage and obtain any required prior authorizations before rendering services. It is the provider's responsibility to confirm benefit coverage, obtain necessary authorizations, and follow any authorization rules and timeframes on the member's plan. Failure to obtain required preauthorization may result in denial or reduced payment.

Verify member eligibility and benefits prior to service.
Obtain prior authorization when required per Neighborhood plan rules.
Follow timeframes and documentation requirements on authorization approvals.

Note

Reevaluation request

A facility may request a reevaluation of Neighborhood's initial payment decision within 60 days of the date of remittance advice. The facility must submit a completed Readmission Reevaluation Request form and include an explanation and any pertinent supporting documentation showing why the original determination should be re-evaluated. Send requests to RReevaluations@nhpmi.org. A decision will be made within 60 days from receipt of all required information. Hospital contracts and any current inpatient preauthorization/notification rules supersede this policy where applicable.

Submit the completed Readmission Reevaluation Request form within 60 days of remittance advice.
Include an explanation and all pertinent supporting documentation.
Send requests to RReevaluations@nhpmi.org.
Decision timeframe: Neighborhood will respond within 60 days of receiving all information.

Key Definitions

Readmission — definition entry

DefinitionAn acute care hospital admission occurring within 30 calendar days of a prior discharge for treatment of the same diagnosis (from the same or another acute care facility in the same healthcare system)

Member liabilityMembers are not liable for claims denied as a readmission

ScopeApplies to unplanned hospital readmissions reviewed for reimbursement determination

Clinically related readmission — definition entry

DefinitionA readmission that is clinically related to a previous admission when it meets one of the following: continuation or recurrence of the prior condition; medical complication related to care during the prior admission; unplanned surgical procedure for continuation/recurrence of the prior problem; or unplanned surgical procedure to address a complication from the prior admission

ExamplesContinuation/recurrence: readmission for diabetes following initial diabetes admission; Complication: UTI after discharge with urinary catheter; Surgical continuation/complication: appendectomy or drainage of postoperative abscess following prior related admission

Review purposeMedical record review determines relatedness to the prior admission — not medical necessity or appropriateness of setting