CurrentFlorida BluePolicy 16-050

Readmissions Review Quality Program / Hospital Readmissions Payment Policy

Defines Florida Blue's reimbursement stance for subsequent inpatient admissions to the same hospital or its satellite occurring within 15 days of a prior discharge, and return transfers from sub-acute care, affecting contracted hospitals and applicable to all Florida Blue benefit plans.

Policy Summary

PayerFlorida Blue

PolicyReadmissions Review Quality Program / Hospital Readmissions Payment Policy

Policy CodePolicy 16-050

Change TypeNo material change

Effective DateDec 11, 2025

Next Review DateN/A

Key ActionHospitals must submit a single or corrected combined claim for same-day readmissions; separate claims may be denied and preventable readmissions may be non-reimbursed with hospital financial liability.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15 daystime window between discharge and subsequent admission evaluated

all linespolicy applicability

hospital liablefinancial responsibility

exclusions listnotable excluded categories

combined billingbilling instruction when readmitted same day

Readmission Reimbursement Criteria

Readmission reimbursement criteria

Coverage and reimbursement determinations for subsequent admissions within the policy window:

Subsequent admissions to the same hospital or a satellite occurring less than 15 days from a prior discharge (neither the day of discharge nor the day of admission is counted).

Clinical review determines relatedness and preventability: a Florida Blue clinical team will review medical records to determine whether the readmission is for treatment of the same or a related condition or procedure from the prior discharge and whether the need for inpatient care could have been reasonably prevented by appropriate discharge planning or post-discharge follow-up.

Reimbursement stance when readmission is judged reasonably preventable: Florida Blue will not provide additional reimbursement for related subsequent admissions determined to be reasonably preventable after clinical review; the original admission's compensation constitutes full reimbursement and the hospital is liable for the preventable readmission. Members are not to be held liable and hospitals may not bill members for preventable readmissions.

Billing when readmission occurs on same day

Policy Summary

PayerFlorida Blue

PolicyReadmissions Review Quality Program / Hospital Readmissions Payment Policy

Policy CodePolicy 16-050

Change TypeNo material change

Effective DateDec 11, 2025

Next Review DateN/A

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 and Billing Expectations

Prior Authorization

Clinical review determines preventability and hospital financial responsibility

Clinical review by a Florida Blue clinical team will determine whether a subsequent inpatient admission within 15 days is for the same or a related condition/procedure and whether the need for inpatient care could have been reasonably prevented by appropriate discharge planning or post-discharge follow-up. Hospitals found to have preventable readmissions will be financially liable and may not bill members for those admissions.

Clinical review evaluates relatedness and preventability based on medical records and accepted standards of care.
If determined preventable, Florida Blue will not provide additional reimbursement and the hospital is solely liable; members must not be billed.

Key Definitions

inv-05: Subsequent inpatient admission definition

DefinitionSubsequent inpatient admission to the same hospital or a satellite occurring less than 15 days from a prior discharge

Return transfersIncludes return transfers from sub-acute care back to the originating hospital or satellite

Counting daysWhen calculating the interval, neither the day of discharge nor the day of admission is counted

inv-06: Preventable readmission definition

DefinitionA readmission judged by clinical review to be for the same or related condition that could have been reasonably prevented by appropriate discharge planning or post-discharge follow-up.

Determination methodClinical team review of medical records to assess relatedness and preventability

Financial consequenceIf deemed reasonably preventable, Florida Blue will not provide additional reimbursement and the hospital is liable; members are not held liable

OpenPayer

Readmissions Review Quality Program / Hospital Readmissions Payment Policy

Readmission Reimbursement Criteria

Billing and Coding Guidance

Clinical Review and Billing Expectations

Key Definitions