Notice of Readmissions Review Occurring Within 30 Days

Attention Hospital Providers:

Effective November 1, 2018, all clinically-related/potentially preventable readmissions occurring within a thirty (30) day period will be subject to review. Readmissions will be denied when any of the following are determined:

  • A patient was prematurely discharged from the same hospital
  • A facility failed to have proper and adequate discharge planning in place, OR
  • If there was a lack of proper coordination between the inpatient and outpatient healthcare teams.

In the absence of information to determine the appropriateness of the readmission, clinically-related/potentially preventable readmissions within a seven (7) day period will be automatically denied and the provider will need to submit medical documentation to support the need for payment. Final review decisions will be made/confirmed by an employed medical director of The Health Plan.

Procedures performed on the wrong side, wrong body part, wrong procedure, or wrong person are commonly referred to as “never events.” As a reminder, all never events are considered not medically necessary and reimbursement is not allowed. Questions regarding claim denials may be directed to The Health Plan’s provider number at 1.877.847.7901.