CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Unplanned Hospital Readmission Reimbursement Policy

Governs NHPRI's review and reimbursement stance for unplanned hospital readmissions within 30 days of a prior discharge for members across Medicaid, Commercial, and INTEGRITY lines of business; applies to contracted and non-contracted facilities.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUnplanned Hospital Readmission Reimbursement Policy

Policy CodePolicy N/A

Change TypeFormat changes only

Effective Date01/01/2021

Next Review DateN/A

Key ActionFacility may request a reevaluation of the payment decision within 60 days of remittance by submitting the Readmission Reevaluation Request Form and pertinent information to HRreevaluations@nhpri.org.

SourceLink

POLICY UPDATE CHANGES

Format changes only. No content changes.

30 daysreadmission window for review

60 daystimeframe to request payment reevaluation

3policy review entries (2020-2023)

Readmission Determination and Exclusions

Readmission determination criteria and exclusions

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Unplanned readmission determined to be clinically related to the previous admission will not be reimbursed (per Policy Statement).

Criteria indicating clinical relatedness

Readmission for continuation or recurrence of the same, similar, or a related condition (e.g., readmission for diabetes following an initial admission for diabetes).
Readmission for a medical complication related to care during the previous admission (e.g., discharged with urinary catheter and readmitted for treatment of a urinary tract infection).
Unplanned readmission for a surgical procedure to address continuation or recurrence of a problem causing 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 admission for a bowel resection).

Exclusions (these are excluded from readmission 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 active chemotherapy malignancies, 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.30 days

Medical record review determines relatedness and is not an assessment of medical necessity or appropriateness of the setting.

Operational: reviewers assess relatedness only; separate medical necessity rules (NCD/LCD/InterQual/Clinical Medical Policies) may be applied for reimbursement determinations.

Coding and Timely Filing Requirements

Required coding standardsmixed

CPT, ICD-10-CM, HCPCS

Coding systems required for claim submission per AMA/CMS/HCPCS standards.

Timely filing

Timely filing requirementSubmit complete claims for payment within contractually determined timely filing guidelines.

ApplicabilityBillable services are subject to contractual agreements when applicable.

Coding standards referenceClaims must follow CPT, ICD-10-CM, and HCPCS Level II coding standards as applicable.

Provider Requests and Contract Rules

Documentation Required

Request payment reevaluation within 60 days

Any facility may request a reevaluation of the payment decision within 60 days of the receipt of remittance advice. The facility must submit a completed Readmission Reevaluation Request Form with an explanation and any pertinent supporting documentation to HRreevaluations@nhpri.org. Neighborhood will issue a decision within 60 days from receipt of all information.

Submit completed Readmission Reevaluation Request Form
Include explanation of why original determination should be re-evaluated
Attach pertinent supporting documentation
Send request to HRreevaluations@nhpri.org
Request must be made within 60 days of remittance; decision issued within 60 days of receipt of all information

Prior Authorization

Follow inpatient preauthorization rules and hospital contracts

Existing inpatient preauthorization or notification rules and hospital contracts remain applicable and supersede the language in this policy where specified. Providers must follow plan-specific prior authorization requirements and hospital contract terms.

Hospital contracts supersede this policy
This policy does not supersede any current inpatient recommended or required preauthorization or notification rules
Verify eligibility, coverage and authorization criteria prior to rendering services and consult Neighborhood’s Prior Authorization Reference page or Provider Services as needed

Key Definitions

Readmission

Readmission definitionAn acute care hospital admission within 30 days of discharge from the same or other acute care facility.

Review purposeNHPRI conducts medical record review to determine relatedness of readmissions to prior admissions.

Outcome implicationClinically related unplanned readmissions may not be reimbursed per policy criteria.

Clinically related readmission

Clinically related readmission - continuation/recurrenceReadmission for continuation or recurrence of the previous same/similar or related condition (e.g., diabetes readmission after initial diabetes admission).

Clinically related readmission - complication of prior careReadmission due to a medical complication related to care during the previous admission (e.g., UTI after discharge with urinary catheter).

Clinically related readmission - unplanned surgical returnUnplanned readmission for a surgical procedure to address continuation/recurrence or a complication from the prior admission (e.g., appendectomy after prior abdominal pain; drainage of post-operative wound abscess).