Provider updates

Effective April 1, 2026, CareOregon is reinstating a policy review process for hospital readmissions within 30 days. This change is being reinstated in an effort to reduce preventable hospital readmissions and is in alignment with the Hospital Readmissions Reduction Program established under the Affordable Care Act (ACA).

What is changing?

Readmissions within 30 days that occur at hospitals within the same hospital system, operating under the same contract or sharing the same tax identification number, will be evaluated as related to the initial admission. These changes apply to Columbia Pacific CCO, Jackson Care Connect, Health Share of Oregon, and CareOregon Advantage. 

Why are we making this change?

The ACA requires Centers for Medicare and Medicaid Services (CMS) to reduce payments to Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions, a mandate that has been in effect since October 1, 2012. Consistent with CMS’s approach—and with Oregon Health Authority (OHA) regulations —CareOregon’s efforts focus on improving quality of care, ensuring safe discharge planning, and aligning reimbursement with clinically appropriate and medically necessary care.

We intend to promote safe and effective discharge planning for CareOregon members and to ensure that payments reflect requirements outlined by CMS and OHA. CareOregon may deny payment for readmissions determined to be clinically inappropriate or preventable based on the following criteria.

30 day readmissions included in review

The following types of readmissions are subject to preventability review:

• Resulted from a prior premature discharge from the same hospital or hospital system
• Resulted from a failure to have proper and adequate discharge planning including failure to have proper coordination between the inpatient and outpatient health care teams; and/or
• Resulted from the circumvention of the contracted rate by the hospital or hospital system
• Readmissions with questionable medical necessity

30 day readmissions excluded from review

The following types of readmissions are not subject to preventability review:

• Transfers from out-of-network to in-network facilities
• Transfers for services not available at the originating facility
• Planned, repetitive, or staged treatments (e.g., chemotherapy, staged surgeries)
• Readmissions related to malignancies, burns, or cystic fibrosis
• Admissions to Skilled Nursing Facilities (SNF), Long-Term Acute Care (LTAC), or Inpatient Rehabilitation Facilities (IRF)
• Readmissions following an Against Medical Advice (AMA) discharge
• Obstetrical readmissions
• Readmissions occurring 31 or more days after the prior discharge
• Infants age ≤ 1 year

CareOregon is committed to collaborating with our hospital partners to improve care transition and ensure clinically appropriate utilization of inpatient services.

You can find additional information in the coding guide on our website.

• CareOregon: Provider coding quick guides
• Jackson Care Connect: Provider coding quick guides
• Columbia Pacific CCO: Provider support

   

 If you have any questions or need further clarification, please do not hesitate to contact CareOregon Provider Relations. 

Provider Relations:

• CareOregon/Health Share: Metrobhprs@careoregon.org
• Jackson Care Connect: jacksonprs@careoregon.org
• Columbia Pacific CCO: colpacPRS@careoregon.org