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Determining initial eligibility for further review

Updated on April 26, 2021

In the CE_IsEligibleforReadmission collection, Smart Claims Engine for Healthcare first determines whether the current claim being adjudicated warrants additional review to determine its potential status as an unplanned hospital readmission.

In this collection, Smart Claims Engine for Healthcare matches the claim header and line level data against the following configurable criteria:

  • Claim form type = Institutional (I)
  • Bill type = 0111, 0112, or 011A

  • Admission source code ≠
    • 4: Transfer from hospital
    • 5: Transfer from skilled nursing facility
    • 6: Transfer from another facility
    • A: Transfer from rural primary care hospital

  • Servicing facility’s primary specialty ≠
    • Taxonomy 282NC0060X: Critical access hospital
    • Taxonomy 282NC2000X: Children’s hospital
    • Taxonomy 283Q00000X: Psychiatric hospital
    • Taxonomy 283E00000X: Long-term care hospital
    • Taxonomy 284300000X: Specialty (e.g., CA) hospital

When the current claim being adjudicated meets all of the initial criteria, Smart Claims Engine for Healthcare then displays its eligibility for further review in the claims history UI.

Claim form type, Bill type, Admission source code meet criteria:

Servicing facility’s primary specialty meets criteria:

Claim history notation:

Reasons for excluding claims, based on not meeting initial criteria, are also indicated in the claims history.

Claim excluded, based on bill type:

Claim history display:

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