UHC MA Dual Special Needs Plan Readmission Guidelines Update

March 2019 ~

Effective June 1, UnitedHealthcare Massachusetts (UHCMA) Community Plan will update the existing Dual Special Needs (DSNP) Readmission Review Program Clinical Guidelines to apply to Massachusetts Senior Care Options. Any inpatient admission will be subject to the readmission review requirements.

UHC states the Readmission Clinical Program Clinical Guidelines are based on CMS billing requirements and the change is consistent with CMS guidance. These guidelines will apply if a care provider submits an inpatient claim within 30 days of a previous inpatient claim for the same member and facility. No further action needs to be taken at this time.

If UHC identifies a readmission claim, the insurer will suspend the claim and request associated medical records for the original claim and the suspended claim. If it is determined that the readmission was preventable, UHC may not reimburse the readmission claim.

Review the Readmission Review Program Clinical Guidelines, here.

Source(s): UnitedHealthcare Network Bulletin March 2019;