Blue Cross and Blue Shield MAPD 30 Day Facility Readmission

Dec. 13, 2019

Consistent with the Centers for Medicare & Medicaid Services (CMS) guidelines, beginning March 1, 2020, Blue Cross and Blue Shield of Montana (BCBSMT) will review acute hospital claims, to determine if such readmissions to the same facility within 30 days of discharge are related and may deny payment to the facility for related admissions. These changes help support quality of care improvement efforts by linking payment to the quality of facility care for our Blue Cross and Blue Shield MAPD (PPO)SM members.

As a provider what should I expect?

  • Beginning March 1, 2020, BCBSMT will perform a clinical review of acute care facility readmissions that occur within 30 days of discharge from the same facility.
  • If BCBSMT determines that a provider has submitted a second claim after a patient has been discharged from an acute in patient stay, BCBSMT may request medical records from the provider.
  • Following CMS guidelines this does not currently affect Critical Access Hospitals (CAH).

As a provider what should I do?

  • Upon request of medical records, the facility must forward related medical records and any documents involving the admissions.
  • If it is determined that the acute stays were clinically related, BCBSMT may deny payment to the facility for the readmission.
  • Providers may dispute determinations through existing processes, which can be found in the provider manual located on our website.

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