CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Unplanned Hospital Readmission Payment/Reimbursement Policy

Governs review and reimbursement for unplanned hospital readmissions within 30 calendar days of a prior discharge; applies to all lines of business and acute care admissions for contracted and non-contracted facilities.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUnplanned Hospital Readmission Payment/Reimbursement Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionFacilities may request a reevaluation of the payment decision within 60 days of receipt of remittance advice by submitting a completed Readmission Reevaluation Request Form with supporting information to HRreevaluations@nhpri.org.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysreadmission window

All linesapplies to

60 daysreeval timeframe

90 daysclaims submission

Readmission Review and Exclusions

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Readmission review criteria and exclusions

NHPRI will review unplanned hospital readmissions that occur within 30 calendar days of a prior discharge to determine clinical relatedness; readmissions determined to be related will not be reimbursed. The following criteria define related readmissions and the exclusions from review.

Review applies to unplanned hospital readmissions that occur within 30 calendar days of a prior discharge from the same hospital or system of care; each readmission will be reviewed against the readmission definition relative to the last covered admission.

Readmission considered clinically related when any of the following are met:

A medical readmission for a continuation or recurrence from the previous admission for the same, similar, or related condition (e.g., readmission for diabetes following an initial admission for diabetes).
A medical complication related to care during the previous admission (e.g., patient discharged with urinary catheter readmitted for treatment of a urinary tract infection).
An unplanned readmission for a surgical procedure to address a continuation or recurrence of a problem causing the previous admission (e.g., readmitted for appendectomy following a previous admission for abdominal pain and fever).
An 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).

Exclusions (these readmissions are excluded from readmission review):

Readmissions that are planned 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 those in an active chemotherapy regimen; 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 (AMA).
Readmissions greater than 30 calendar days from the last discharge are excluded from review.

Coding Standards and Timeframe

Required coding standardsmixed

CPT, ICD-10-CM, HCPCS

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

Readmission timeframe threshold

Readmission timeframe thresholdReadmissions greater than 30 calendar days from the last discharge are excluded from readmission review.

Applies toAll lines of business (Medicaid, Commercial, and INTEGRITY).

Effect of exclusionExcluded readmissions are not subject to the clinical relatedness review for non-reimbursement determination.

Provider Responsibilities and Appeals

Documentation Required

Request a reevaluation within 60 days using the Readmission Reevaluation Request Form

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 of why the original determination should be re‑evaluated and include any pertinent supporting information. Send requests to HRreevaluations@nhpri.org. A decision will be made within 60 days from receipt of all information.

Submit completed Readmission Reevaluation Request Form
Include explanation of why original determination should be re‑evaluated and any pertinent supporting information
Send to HRreevaluations@nhpri.org
Requests must be made within 60 days of receipt of remittance advice
NHPRI will decide within 60 days of receipt of all information

Key Definitions

Definition of Readmission

Core definitionAn acute care hospital admission occurring within 30 days of discharge from the same or another acute care facility.

Relatedness — continuation/recurrenceA readmission for continuation or recurrence of the previous condition (e.g., readmission for diabetes following an initial diabetes admission).

Relatedness — complication of prior careA readmission for a medical complication related to care during the previous admission (e.g., urinary tract infection after discharge with a urinary catheter).

Relatedness — surgical recurrence or complicationAn unplanned readmission for a surgical procedure to treat a continuation/recurrence or a complication from the prior admission (e.g., appendectomy after prior admission for abdominal pain; drainage of a post‑operative wound abscess after bowel resection).