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Claims and Payment Policy: Inpatient Readmission

August 18, 2022

‘Ohana Health Plan has historically evaluated inpatient readmissions based on a Pre-Payment Review, identifying claims that are most likely avoidable or preventable readmissions and therefore, denying the second payment. The provider would then have the right to dispute or appeal. If the readmission was deemed not related nor preventable, ‘Ohana would release the payment for the second readmission, or if determined to be preventable or related to the hospitalization, we would uphold the denial.

This letter is notification that ‘Ohana Health Plan will be changing our Inpatient Readmission review Policy to a Post-Payment Review effective October 1, 2022.

Payment Timing: 

  • For admit date on or after 10/01/22
  • ‘Ohana Health Plan will identify which claims are most likely avoidable or preventable readmissions for denial and request a refund. The identification is based on billed DRGs as well as the same or similar diagnoses found on the two related hospital claims.
  • If the provider disagrees with ‘Ohana’s determination, the provider has the right to appeal/dispute the determination. The provider must submit medical records for both admissions to ‘Ohana or its contracted vendor. ‘Ohana will then evaluate the records to determine if the second admission was preventable or related to the first admission.
  • If it is determined that the second record is not a related readmission, the provider will be notified, and no additional actions will occur.
  • If ‘Ohana determines the second admission was preventable and related to the hospitalization, the provider will be notified of the denial, or the requested refund will be upheld.

If you have any questions or concerns regarding the reimbursements, please contact Customer Service at 1-888-846-4262. TTY users may call 711. We’re here for you Monday-Friday, from 7:45AM to 4:30PM, Hawai’i Standard Time.

Thank you for your partnership with ‘Ohana Health Plan. We thank you for continuously striving to achieve the best care for our members.

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Y0020_WCM_87476E Last Updated On: 8/18/2022