Updated 30-Day Readmission Payment Policy

Fecha: 07/08/20

Updated 30-Day Readmission Payment Policy

Effective September 15, 2020

We are happy to inform you that Ambetter from Sunflower Health Plan is publishing its payment policies to inform providers about acceptable billing practices and reimbursement methodologies for certain procedures and services. We will apply these policies as medical claims reimbursement edits within our claims adjudication system. This is in addition to all other reimbursement processes that Ambetter from Sunflower Health Plan currently employs.

Sunflower believes that publishing this information will help providers to bill claims more accurately, therefore reducing unnecessary denials and delays in claims processing and payments. These policies address coding inaccuracies including diagnosis to procedure code mismatch, inappropriately modified procedures, unbundling, incidental procedures, duplication of services, medical necessity requirements and health plan specific payment rules for procedures and services.

These policies are developed based on medical literature and research, industry standards and guidelines as published and defined by the American Medical Association’s Current Procedural Terminology (CPT®), Centers for Medicare and Medicaid Services (CMS), and public domain specialty society guidance, unless specifically addressed in the fee-for-service provider manual published by the state of Kansas or regulations.

Visit our Clinical and Payment Policies page  to find the payment policies. The effective date for the below policy is September 15, 2020.

CC.PP.501 - 30 Day Readmission:

The purpose of this payment policy is to provide a guide to payment, which is a component of the guidelines used to assist in making coverage and payment determinations and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage and payment determinations and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable plan-level administrative policies and procedures.