[Georgia] 30-Day Readmission Policy

Immediately: Billing team must implement the following procedures for all Georgia Medicaid hospital admissions: (1) Flag all inpatient claims submitted within 30 days of a previous discharge to the same facility for readmission review; (2) When submitting readmission claims originating from the same facility or TIN, automatically attach complete medical records from BOTH the initial and readmission encounters with the claim submission in the billing system; (3) Do NOT submit readmission claims for same/related conditions within 30 days as separate DRG claims—consolidate into one claim unless clinical justification for appropriate readmission is documented; (4) Update claim submission templates and billing software validation rules to require dual medical record attachment for same-facility readmissions; (5) Train billing and claims staff to identify same/related diagnoses (including complications like retained placenta) and apply this policy; (6) Establish process to request and review documentation from providers when CareSource requests records for prepayment or post-payment review—failure to provide complete records will result in automatic denial. Consequences: Claims will be denied or recouped if medical records are incomplete or missing, readmissions are deemed preventable, or justification is inadequate.