CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Unplanned hospital readmission reimbursement

Governance of NHPRI reviews for unplanned hospital readmissions occurring within 30 calendar days of a prior discharge and reimbursement denial when readmissions are deemed clinically related; applies to all lines of business and both contracted and non-contracted facilities.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUnplanned hospital readmission reimbursement

Policy CodePolicy N/A

Change TypeOperational (format/date) — no material coverage changes

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionFacility may request reevaluation of a payment decision within 60 days of remittance by submitting the Readmission Reevaluation Request Form with supporting information to NHPRI.

SourceLink

POLICY UPDATE CHANGES

Document history notes a policy review on 10/01/2022 limited to date format changes with no content changes.

30 daysreadmission window for review

All lineslines of business

60 daysreevaluation timeframe

May be requesteddocumentation

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Readmission review criteria and exclusions

NHPRI will review medical records to determine clinical relatedness; if related, the unplanned readmission will not be reimbursed. Certain scenarios are excluded from review.

Readmission review applies to unplanned hospital readmissions occurring within 30 calendar days of a prior discharge.

Unplanned readmission is considered clinically related when ANY of the following are met:

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

Effect: If the unplanned readmission is determined to be clinically related to the previous admission, the readmission will not be reimbursed.

Exclusions — readmissions that are excluded from readmission review (do NOT trigger denial under this policy):

Planned or repetitive treatments (for example, cancer chemotherapy, transfusions for chronic anemia, or other similar repetitive treatments) or scheduled elective surgery are excluded from readmission review.
Readmissions due to malignancies limited to members who are in an active chemotherapy regimen, burns, or cystic fibrosis are excluded from review.
Readmissions due to organ or bone marrow transplants are excluded from review.
Obstetrical admissions are excluded from review.
Readmissions with a documented discharge status of 'left against medical advice' are excluded from review.
Readmissions greater than 30 calendar days from the last discharge are excluded from review.

Coding Standards and Timing Threshold

Coding standardsmixed

Coding must meet AMA CPT, ICD-10-CM, and HCPCS standards

Readmission timing threshold

ThresholdReadmissions greater than 30 calendar days from the last discharge are excluded from readmission review

ApplicationApplies to unplanned hospital readmission reviews conducted by NHPRI to determine clinical relatedness

EffectIf excluded by timing (>30 days), the readmission will not be subject to clinical relatedness review under this policy

What Providers Must Do

Prior Authorization

Eligibility and Prior Authorization Note

Providers must verify member eligibility, coverage benefits, and whether prior authorization is required before rendering services. Prior authorization rules, employer or hospital contract requirements, and plan-specific limits may supersede general policy language. If prior authorization is required by Neighborhood Health Plan of Rhode Island, obtain approval through the plan's Prior Authorization process prior to performing the service to avoid claim denials.

Verify member eligibility and coverage prior to service.
Confirm if prior authorization is required and obtain approval when applicable.
Follow any employer/hospital contract requirements that may supersede this policy.

Note

Reevaluation Request Process

A facility may request a reevaluation of an initial payment decision within 60 days of receipt of the remittance advice. The facility must submit a completed Readmission Reevaluation Request Form and include a clear explanation of why the original determination should be re-evaluated. Include any pertinent clinical or billing documentation to support the request. Send requests to HRreevaluations@nhpri.org. Neighborhood will make a decision within 60 days from receipt of all required information.

Submit Readmission Reevaluation Request Form within 60 days of remittance advice.
Include explanation and supporting documentation for re-evaluation.
Send to HRreevaluations@nhpri.org; expect a decision within 60 days of complete submission.

Key Definitions

Readmission — definition

DefinitionAn acute care hospital admission within 30 days of discharge from the same or other acute care facility

ContextNHPRI conducts unplanned hospital readmission reviews to determine if the readmission was clinically related to the previous admission

Reimbursement ImplicationUnplanned readmissions determined to be clinically related to the previous admission will not be reimbursed

Clinically related readmission — definition

DefinitionAdmission for continuation or recurrence of the same or related condition, or for a complication related to prior care

ExamplesContinuation/recurrence of prior condition (e.g., diabetes readmission after initial diabetes admission); complication from prior care (e.g., UTI after discharge with catheter)

Surgical ExamplesUnplanned surgical readmission to address recurrence or complications from the previous admission (e.g., appendectomy after prior abdominal admission; drainage of post‑operative wound abscess)