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Diagnosis-related group (DRG) readmission payment policy

 

As a reminder of our readmissions payment policy: This policy applies to both Commercial and Medicare Advantage products. This policy applies to participating acute care facilities contracted with DRG rates.


We will not recognize and reimburse another DRG for members who are readmitted to the same facility for symptoms related to, or for the evaluation and management of, the prior stay’s medical condition within 30 calendar days. The subsequent admission is considered to be included in the DRG from the initial admission.  


The following types of admissions are excluded from this policy:
 

  • Readmissions unrelated to the initial admission
  • Planned readmissions
  • Readmissions due to an unavoidable complication
  • Readmissions after the member left the facility against medical advice (AMA) for the initial admission