Washington Medicaid: What to expect from a 14-day readmission review

Last modified: August 17, 2021

The Washington Health Care Authority (HCA) has certain requirements for claims to be paid when a Medicaid member is readmitted to the hospital within 14 days of an inpatient stay.

We want you to have all the information you need so you can know what to expect if we conduct a review of a 14-day readmission for a UnitedHealthcare Community Plan member.

What happens if a member is readmitted

If a member is readmitted to the hospital within 14 days, we conduct a clinical review of both admissions to determine if the readmission was preventable due to inadequate and/or incomplete discharge planning from the prior admission. We may request medical records during the review process.

If we determine the readmission was preventable, we’ll recoup payment for the second admission. If this happens, you’ll have the option to appeal.

Learn more

Please see our list of frequently asked questions to learn more about this process, including:

• What’s considered a readmission
• How we define a “preventable readmission”
• What your appeal rights are if we determine a readmission was preventable

Questions?

Contact your hospital advocate or call Provider Services at 866-574-6088.

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