NY Manual
SHP Manual

New York Provider Manual
17.7 Overpayments | 18 Glossary of Terms

17.8 Avoidable Readmission Reimbursement Policy

Healthfirst's Avoidable Readmission Reimbursement Policy is designed to reduce avoidable readmissions to improve quality of care. Healthfirst will deny any claim for an acute-care hospital admission that meets the criteria for an avoidable readmission, as defined in this policy. This policy applies to all inpatient claims across all lines of business.
An avoidable readmission is one that occurs within 30 days of discharge of the index (i.e., initial) admission from the same hospital or hospital system, for a condition with the same, a similar, and/or a related diagnosis group (same major diagnostic category (MDC)), provided that none of the exceptions listed below applies.
Subsequent admissions will not be subject to denial under this policy if any of the following is true:
 
» Patient transferred from out of network (OON) to in network (INN),
» Patient transferred to an inpatient rehabilitation facility,
» Patient transferred to a skilled nursing facility (SNF)
» Patient transferred to receive care not available at the first facility,
» The subsequent admission was a planned readmission for repetitive treatments (e.g., chemotherapy for cancer),
» The subsequent admission was a scheduled readmission for elective procedures,
» Patient left Against Medical Advice (AMA) from the index admission,
» Patient expired during the subsequent admission,
» Patient was enrolled in hospice during the subsequent admission,
» The index admission and/or subsequent admission was for:
o trauma, burns, malignancies, cystic fibrosis, eye, mental health, substance use
disorders,
» The subsequent admission was to a psychiatric/substance abuse unit or facility
» The subsequent admission was related to treatment for pregnancy and/or newborns, or
» The subsequent admission occurred more than 30 days from discharge from the index
admission.
 
If you feel a claim was denied in error or would like to dispute a denial, please follow the claim reconsideration and appeal process outlined in your Healthfirst Provider Manual.
Review Process:
 
1. If Healthfirst determines that the admission is a readmission of the index, the hospital will be notified of the claims denial.
2. The hospital has the right to a claims review and reconsideration (1st level) and to a claims appeal (2nd level) of the determination. Denial of payment for the claim will be upheld unless it can be shown that the admission does not meet the criteria for an avoidable readmission.
3. The claims review and reconsideration, and the claims appeal process, will follow the Healthfirst standard claims reconsideration process as documented in Section 17.6 of this Provider Manual. If it is determined on appeal that the readmission did not meet the criteria for an avoidable readmission, the admission will be reimbursed in accordance with the terms of the applicable Participating Hospital Agreement.
4. Failure of the hospital to provide complete medical records from the index hospitalization and readmission hospitalization for review and reconsideration may result in an adverse determination under the reconsideration process.
5. Healthfirst reserves the right to look back within the maximum allowed recovery time frame per state guidelines or per specific provider contract to identify any claims that may be for an avoidable readmission.
6. Healthfirst reserves the right to deny the claim or to recoup and/or recover monies previously paid on a claim that is within the guidelines of this policy.

Members may not be charged for hospital admissions denied as avoidable readmissions under this policy.​​