Description
This policy addresses reimbursement guidelines for readmission to inpatient acute care hospital stay.
Definition
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Readmission
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Unplanned inpatient acute care hospital readmission for the same patient within 15 days of discharge of the previous inpatient hospital stay for a condition related to the most recent inpatient hospital stay.
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Policy
Blue Cross Blue Shield of North Dakota (BCBSND) will not separately reimburse acute care hospitals for a readmission occurring within fifteen (15) days of discharge from the same hospital for the same member for a related admission. The readmission policy is based on fifteen (15) calendar days, not hours.
Related Readmission Reasons (not intended to be an exhaustive list):
- The same or a closely related condition or procedure as the original admission
- An infection or other complication of care arising from the original admission or post discharge care
- A condition or procedure indicative of a failed surgical intervention
- An acute decompensation of a coexisting chronic disease that may be related to care during the initial admission or follow up care after discharge
- Clinical instability of the patient’s condition prior to discharge (premature discharge) or not providing proper care coordination or discharge planning during the admission or during the post-discharge follow-up period.
Limitations and Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
History
Date
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Updates
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5/02/2022
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Created Inpatient Readmissions policy from information published in HealthCare News January 2017 Issue.
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3/1/2023
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Updated days from 6 to 15 effective with admit date of service 4/1/23.
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9/15/2024
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Policy annual review completed.
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