In executing the hospital readmission audit, Smart Claims Engine for Healthcare leverages CMS’ definition of an unplanned hospital readmission, including:

• A 30-day look-back period for unplanned hospital readmissions.
• Application of readmission rules to short-stay, acute hospitals.
  • Certain hospitals types are excluded based on taxonomy.
• Exclusion of certain planned admissions, based on procedures and diagnoses.

Smart Claims Engine for Healthcare executes the hospital readmission audit logic in the CE_HospitalReadmissions collection, in the CE_BusinessAudits adjudication module.

• ICD-10-Diagnosis-codes
• Determining initial eligibility for further review
• Excluding planned admissions
• Planned admission types
• Identify a planned admission
• Identifying suspect index claims
• Resolving an unplanned readmission
• Waive member co-pay
• Manually reprice claim line

• Hospital readmission audits