This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care.
Effective Jan. 1, 2026, the Acute Inpatient Hospital Services policy has been updated to add readmission review criteria and change the readmission review timeframe. This update will:
- Change the readmission quality review timeline from 72 hours after discharge to 30 days after discharge
- Define criteria that will be exempt from utilization review measures based solely on occurring within 30 days of an inpatient index stay for the same or similar diagnosis:
- Cancer hospitals, critical access hospitals, planned hospital transfers and inpatient rehabilitation centers
- Medical treatment of cancer
- Psychiatric illness
- Rehabilitation
- Planned readmission
- Under age 2 years
- Discharge against medical advice during index stay
- Pregnancy, childbirth and puerperium
- Organ or tissue transplant inclusive of patients under active evaluation for transplant, listed for transplant or post-transplant
- Sickle cell anemia
- Cystic fibrosis
- Authorization denial for inpatient, continued stay or post-acute care for the patient at the index admission, visit or stay.
For beneficiaries enrolled in a managed care plan (PHP), providers should contact the appropriate health plan for that beneficiary.
Contact
NCTracks Call Center: 800-688-6696
Health Plan Contacts and Resources