CurrentAnthemPolicy N/A

Inpatient Readmissions reimbursement

Defines Anthem's reimbursement stance for inpatient readmissions to the same hospital for the same, similar, or related condition and the circumstances under which separate payment will not be allowed; applies to claims for Anthem Blue Cross and Blue Shield (BadgerCare Plus) members. Affects facilities and providers submitting inpatient claims.

Policy Summary

PayerAnthem

PolicyInpatient Readmissions reimbursement

Policy CodePolicy N/A

Change TypeMaterial language added

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionDo not bill separately for readmissions to the same hospital within 30 days for the same, similar, or related condition unless contracts require otherwise.

SourceLink

POLICY UPDATE CHANGES

Language added explaining that reimbursement is not allowed for the first admission when a member is readmitted for the same or similar diagnosis.

Different hospital language previously present was removed.

30 daysreadmission window considered for non-payment

day 2–30range requiring clinical review

same datesame-date rule

exclusions listedexplicit exclusions

Inpatient Readmission Coverage Criteria

Inpatient readmission coverage criteria

Anthem will not separately reimburse readmissions to the same hospital for the same, similar, or related condition; in the absence of overriding provider/state/federal/CMS mandates Anthem uses the following standards and clinical review to determine relatedness.

Readmissions up to 30 days from discharge are subject to review and potential non-payment.

ALL of the following

Same diagnosis or diagnoses that fall into the same grouping.
Readmissions occurring on the same date of service are considered a continuation of initial treatment and should be combined (same-day readmissions treated as part of the original admission).
Same-day continuation: combine claims; no separate reimbursement for same-date readmission.

ALL of the following

Policy Summary

PayerAnthem

PolicyInpatient Readmissions reimbursement

Policy CodePolicy N/A

Change TypeMaterial language added

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionDo not bill separately for readmissions to the same hospital within 30 days for the same, similar, or related condition unless contracts require otherwise.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Clinical review is utilized for readmissions from day 2 through day 30 to determine if the second admission is for: the same or closely related condition or procedure as the prior discharge; an infection or other complication of care; a condition or procedure indicative of a failed surgical intervention; an acute decompensation of a coexisting chronic disease; a need that could reasonably have been prevented by appropriate prior care or follow-up; an issue caused by premature discharge from the same facility; or a reason that is medically unnecessary.

Payment priority: Anthem does not allow payment for the first admission when a member is readmitted for the same or similar diagnosis.

Exclusions (these admissions are excluded from readmission non-payment)

Admissions for medical treatment of cancer.
Admissions for primary psychiatric disease.
Admissions for rehabilitation care.
Planned readmissions.
Patient transfers from one acute care hospital to another.
Patients discharged from the hospital against medical advice.

Billing and Coding Requirements

Billing codes requirementmixed

CPT/HCPCS/Revenue codes

Services should be billed with CPT, HCPCS and/or revenue codes; billed codes must be supported in the medical record.

Claims submission coding requirementmixed

Industry standard compliant codes

You are required to use industry standard, compliant codes on all claim submissions; billed code(s) are required to be fully supported in the medical record and/or office notes.

Readmission time window

Readmission timeframe (days)30 days

Clinical review windowDay 2–30 (licensed clinical medical review used to determine relatedness)

Same‑day ruleReadmissions on the same date are considered continuation of the initial admission (combined)

Authorization, Review, and Denial Risk

Denial Risk

Readmission review and denial risk — separate payment not allowed within 30 days

Anthem will not allow separate reimbursement for readmissions to the same hospital for the same, similar, or related condition within 30 days unless provider/state/federal/CMS contracts require otherwise. Clinical review is used for readmissions from day 2 to day 30 to determine relatedness; readmissions occurring on the same date are considered part of the original admission and should be combined. Anthem may recoup previously paid monies if a claim meets the readmission guidelines, and note that Anthem does not allow payment for the first admission when a member is readmitted for the same or similar diagnosis.

Readmissions up to 30 days from discharge are subject to review.
Licensed clinical medical review applied for day 2–30 to determine if the second admission is for the same/related condition, infection/complication, failed surgical intervention, acute decompensation, preventable need, premature discharge, or medically unnecessary reasons.
Readmissions on the same date are combined with the original admission (treated as continuation of initial treatment).
Anthem reserves the right to recoup/recover payments and does not allow payment for the first admission when a member is readmitted for the same or similar diagnosis.

Key Definitions

Readmission — definition

DefinitionA readmission is a subsequent admission to the same hospital for the same, similar, or related condition occurring within the readmission timeframe (up to 30 days from discharge).

Clinical review basisReadmissions from day 2 to day 30 are evaluated by licensed clinical medical review to determine if the second admission is for the same/related condition, infection/complication, failed surgical intervention, acute decompensation of chronic disease, preventable need, premature discharge, or medically unnecessary reasons.

Payment implicationAnthem does not allow separate reimbursement for such readmissions unless provider/state/federal/CMS contracts require otherwise; Anthem may recoup monies previously paid when guidelines are met.

Same‑day readmission

Same‑day readmission ruleReadmissions occurring on the same day for symptoms related to or for evaluation/management of the prior stay’s condition are considered part of the original admission and should be combined; a readmission to the same hospital on the same date is treated as a continuation of initial treatment.

Billing treatmentDo not separately bill or expect separate reimbursement for same‑date readmissions; combine with the original admission.

Exclusions relevanceSame‑day rule applies unless exclusions (e.g., cancer treatment, primary psychiatric disease, rehabilitation, planned readmissions, transfers, AMA discharges) override readmission non‑payment determination.