HealthTeam Advantage Readmission Policy

HealthTeam Advantage has implemented a Readmission Policy (effective January 1, 2025) that outlines how acute inpatient hospital readmissions are reviewed and reimbursed under our Medicare Advantage plans. 

Key Highlights

• HealthTeam Advantage reviews acute inpatient readmissions that occur within 30 calendar days of discharge from the same hospital or hospital system. 
• Readmissions are evaluated to determine whether they are clinically related to the initial (index) admission or represent a new, unrelated condition. 

Related Readmissions

A readmission may be considered related when it: 

• Involves the same, similar, or related diagnosis 
• Is due to a complication, infection, or continuation of care 
• Reflects progression of the original condition or a potentially premature discharge 

What This Means for Providers

• Related readmissions may not be separately reimbursed 
• The readmission claim may be denied, adjusted, or bundled with the original stay 
• A corrected combined DRG claim may be required 
• Medical records must be submitted when requested to complete the review 

Unrelated Readmissions

A readmission is generally considered unrelated when it: 

• Is for a new and distinct condition 
• Results from unrelated trauma or injury 
• Is a planned or scheduled admission (e.g., chemotherapy, staged procedures) 

Unrelated readmissions are processed and reimbursed as separate inpatient stays in accordance with HealthTeam Advantage contracts and Medicare Advantage rules. 

Important Exclusions

The following are not treated as related readmissions, including but not limited to: 

• Planned or staged admissions 
• Trauma or unrelated injuries 
• Obstetric admissions 
• Psychiatric or substance use admissions 
• Hospice admissions 
• Transfers between facilities 
• Admissions following discharge Against Medical Advice (AMA) 

Prior Authorization

This policy does not replace or change prior authorization or concurrent review requirements, which continue to apply independently. 

Provider Action

• Submit complete and timely medical records when requested 
• Ensure documentation clearly supports whether the admission is new or related 
• Follow standard billing and prior authorization requirements 

For full policy details or questions, please contact Provider Services.