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30-Day Readmission Policy
Posted By Admin on December 04, 2017
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The state of New Jersey recognizes the importance of controlling avoidable hospital readmissions. To better manage these costs, Horizon NJ Health has changed how we reimburse hospitals and providers for hospital readmissions that take place less than 30 calendar days after the original date of discharge. Effective January 1, 2018, Horizon NJ Health’s new policy states that we will no longer reimburse providers for any health care costs related to a hospital readmission that happens less than 30 calendar days from the first admission unless it is determined that the readmission was medically necessary.

Hospital readmissions is a major contributor to the cost of medical care, both in New Jersey and nationwide. The measure of hospital readmissions within 30 days of discharge is a recognized indicator of quality of care. Our new policy is based on guidelines created by the Centers for Medicare & Medicaid Services (CMS) as part of its Quality Improvement Organization (QIO) Program.

Horizon NJ Health will review all hospital readmission cases to determine if the cases were:

  • Medically necessary
  • Not a result of premature discharge of the patient from the same hospital
  • Not a result of a lack of coordination in the transition of care between the acute care faculty and the outpatient setting
  • Not cases in which the care rendered on readmission could have been provided during the initial admission.

This policy will have no direct impact on our members’ financial responsibility for the care provided, and members will not be charged for hospital readmissions. The full policy is available on the Reimbursement Policies & Guidelines section of our website. If you have more questions about the policy, please call Provider Services at 1-800-682-9091.  Click here to view Frequently Asked Questions.