Date Issued: 2/8/2018 ; Updated 4/25/2022
Update: A formal reimbursement policy with updated guidelines, effective August 30, 2022 to address hospital readmissions is now available.
Starting on June 1, 2018, EmblemHealth is changing its hospital readmission policy to align with the Centers for Medicare & Medicaid Services’ (CMS) guidance. The key change to the readmission policy is as follows:
A second admission to the same hospital or hospitals within the same hospital system within thirty (30) calendar days of a member’s discharge for the same or similar diagnosis will be subject to a clinical review.
For facilities that bill under diagnosis-related groups (DRGs) or case rates:
- Relapse of conditions noted on the first admission
- Complications of treatment or diagnostic investigations
- Insufficient stabilization of patient’s condition prior to discharge
The admission will be denied and a benefit denial will be issued. The facility will be advised of its grievance rights. In the event that a readmission case requires additional clinical information and it is provided by the facility, the review determines if the circumstances of the second admission are related to the first admission.
For facilities that bill per diem (by the day):
- We will not make any changes or additions to the first hospital admission. The second admission will only be approved if we decide it's a separate event from the first admission.
- If the second admission is deemed a continuation of the first admission, it will be denied. A benefit denial will be sent with instructions about how to file a grievance (complaint).
Facilities may ask for the claim to be reconsidered (a peer-to-peer discussion) and reopened (Medicare only). If the facility sends additional clinical information, EmblemHealth will review the claim and decide if the second admission is related to the first.