June 20, 2019
Based on feedback from our provider network, Premera has updated the clinical criteria and process used to determine if a readmission is related to a prior inpatient hospitalization. The updated process is effective for dates of service after April 8, 2019. Read the complete payment policy, including added exclusions.
A readmission is a hospital admission which occurs within 14 days of discharge from a prior admission within the same hospital system and is clinically related to the index admission. Providers may appeal an initial determination and denial of payment for the readmission if there’s evidence that the readmission was unrelated to the initial admission or if the readmission is considered unavoidable.
For an appeal, the hospital system physician must submit the rationale for consideration of overturning the denied stay as unrelated or unavoidable. A Premera medical director and/or a same specialty review provider will then review the readmission.
The goal for this policy is for our members to get better care. This continues to be a quality initiative focused on discharge planning, barrier removal, and patient/caregiver education.