The following outline, designed to be used in conjunction with the more comprehensive DRG Readmissions guidelines(s) , will assist facilities in identifying when a subsequent readmission will be treated as a separate episode or combined with a previous admission.
Readmission within 30 days:
- Both admissions are reviewed for medical necessity. A determination of inpatient approval or denial for each admission is made based upon InterQual guidelines and/or a Medical Director decision.
- Medicare Advantage readmissions, within 30 days of discharge, are reviewed to determine relatedness and if the admissions should be combined.
- Medicaid readmissions, within 15 days of discharge, are reviewed to determine relatedness and if the admissions should be combined
- Admissions will be reviewed to determine if the subsequent admission should be viewed as part of the original admission and if reimbursement for services should be combined, based upon readmission outline and/or the facility’s contract.
- Medicare 30 day readmission considerations will be performed for HealthPlus contracted hospitals ONLY.
- Facility’s may appeal any determinations made by HealthPlus by submitting supporting documentation to HealthPlus’ Utilization Review Department:
HealthPlus of Michigan
PO Box 1700
Flint, MI 48501-1700
ATTN: Utilization Review Department