Medicare AdvantageAdministrativeHigh impact
Update to inpatient readmission review & appeal processes
Priority Health·MI·Prior Authorization
Effective date
Mar 1, 2026
We identified it
Jun 16, 2026
Summary
Medicare plans will now review inpatient readmissions after claim submission rather than during prior authorization. Billing teams may receive authorization approval but later see claim denials due to readmission rules, with different dispute processes depending on when the denial occurs.
Action Required
Immediately: Billing team must update workflows to expect potential claim denials even with prior authorization approval for Medicare inpatient readmissions. Train staff on new dispute processes: use claim dispute process for pre-payment denials, and appeal directly to vendor within 30 days for post-pay audit denials. Monitor remittance advice for denial codes like u98 and audit findings letters from vendors.