Children’s Hospital - A separately certified children’s hospital either freestanding or hospital-within-hospital that has a CMS certification number that has the last 4 digits in the series 3300-3399; and predominantly treats individuals under 21 years of age.
Leave of Absence - A patient who requires follow-up care or elective surgery may be discharged and readmitted or may be placed on a leave of absence. Hospitals may place a patient on a leave of absence when readmission is expected or planned and the patient does not require a hospital level of care during the interim period. Examples could include but are not limited to situations where surgery could not be scheduled immediately, a specific surgical team was not available, bilateral surgery was planned, or when further treatment is indicated following diagnostic tests but cannot begin immediately. Institutional providers may not use the leave of absence billing procedure when the second admission is unexpected.
Readmission - An inpatient admission which occurs within seventy-two (72) hours of discharge from an inpatient stay at the same hospital, or as defined in the Hospital/Provider Contract.
Readmission to the same hospital (assigned provider identifier by our health plan) for the same, similar or related condition, is considered a continuation of initial treatment. Our health plan will not reimburse or permit a facility to retain reimbursement for the readmission. The two hospital admissions will be consolidated into one with all necessary codes, billed charges and length of stay combined. The maximum allowable for the consolidated stay will be recalculated using the methodology defined in the hospital contract.
This policy applies to claims processed using the Diagnosis Related Group (DRG) methodology.
Readmission to the same hospital within 72 hours of discharge or as defined in the Hospital/Provider Contract, is subject to clinical review to determine if the readmission is related to or similar to the initial admission.
This policy applies to the following but not limited to:
- Clinically related readmissions
- Planned readmissions or leave of absence
Emergent readmissions
This policy does not apply to the following:
- Transfer from one inpatient stay at an acute care hospital to an inpatient stay at another acute care hospital
- Patient discharged from the hospital against medical advice
- Planned readmissions for cancer chemotherapy, transfusion for chronic anemia, or other similar repetitive treatments
- Readmission for unrelated condition
- Readmission for the medical treatment of rehabilitation care
- Readmission for pre-delivery obstetrical care
- Psychiatric and substance abuse
- Transplants
- Children's Hospitals
Critical Access Hospitals
Centers for Medicare & Medicaid Services (CMS) Claims Processing Manual, Chapter 3 - Inpatient Hospital Billing, 40.2.5
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Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.