February 27, 2024
As a reminder, BCBSIL performs clinical reviews of acute care facility readmissions that occur within 30 days of discharge of our Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM members, or consistent with your provider contract. If we determine that the acute stays were clinically related, we may deny payment to the facility for related admissions.
We’ve conducted these reviews since March 1, 2020, to support quality improvement, consistent with Centers for Medicare & Medicaid Services guidelines.
When we request medical records for a 30-day facility readmission review to a facility:
- The facility must forward related medical records and any documents involving the admissions.
- If it is determined that the acute stays were clinically related, BCBSIL may deny payment to the facility for the readmission.
- Providers may dispute determinations through existing processes. See our provider manuals for more information.
CMS resources
- Medicare Claims Processing Manual, Chapter 3, Section 40.2.5 (Repeat Admissions)
- Medicare Quality Improvement Organization Manual, Chapter 4, Section 4240 (Readmission Review)