CurrentFlorida BluePolicy 16-050

Readmissions Review Quality Program

Governs Florida Blue's payment determination 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 facilities; applies to contracted hospitals and all Florida Blue lines of business and providers.

Policy Summary

PayerFlorida Blue

PolicyReadmissions Review Quality Program

Policy CodePolicy 16-050

Change TypeNo material changes

Effective DateDec 12, 2024

Next Review DateDec 12, 2024

Key ActionHospitals must submit a single or corrected claim combining same-day readmissions to avoid systematic denial; Florida Blue will not reimburse related preventable subsequent admissions after clinical review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15 daystime window for readmission review

All linesapplies to lines of business and providers

$0member liability

Listedexamples provided

16-050policy id

Readmission Coverage Determination

Readmission reimbursement criteria and exceptions

Covered when ALL of the following are met; clinical review determines the readmission is related to the prior admission and reasonably preventable. When criteria are met, no additional reimbursement is provided to the hospital and the member is not liable.

Readmission occurs less than 15 days from prior discharge (neither the day of discharge nor the day of readmission is counted).

Applies to subsequent admissions to the same hospital or a satellite and return transfers from sub-acute facilities to the originating hospital/satellite.

Readmission is for the same or a related condition or procedure as the prior admission as determined by clinical review of the medical record.

Clinical review determines the need for inpatient care could have been reasonably prevented by provision of care consistent with accepted standards during prior discharge planning and post-discharge follow-up.

If the above conditions are met, Florida Blue will not provide additional reimbursement for the subsequent admission; compensation for the original admission constitutes full reimbursement and the hospital is solely liable (members are not to be billed).

Policy Summary

PayerFlorida Blue

PolicyReadmissions Review Quality Program

Policy CodePolicy 16-050

Change TypeNo material changes

Effective DateDec 12, 2024

Next Review DateDec 12, 2024

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.

Original admission may be reprocessed and prior payments recouped if the subsequent admission is deemed the eligible admission under specified circumstances (e.g., surgery cancelled due to OR scheduling conflict, delay in equipment acquisition, unavailable surgical team).

Exceptions (policy does not apply to the following examples)

Discharge against medical advice.
Hospice care.
Planned or staged readmissions following commonly accepted procedures.
Obstetrical care.
Sickle cell crisis.
Psychiatric admissions.
Transplant and transplant-related care.
Repetitive treatments such as chemotherapy or transfusions.
Cancer treatment as a principal diagnosis.
Acute care for confirmed COVID-19.
Conditions unrelated to the initial admission.
Admissions to Critical Access Hospitals (policy exclusion).

Billing requirement for same-day readmission: hospitals must submit a single claim or corrected bill combining both admissions when readmission occurs on the same day as discharge; filing two separate claims may trigger systematic denial.

See billing/coding instructions for claim submission details.

Same-day Readmission Billing Instructions

Same-day readmission billing

Billing expectationWhen a patient is readmitted to the same hospital on the same day of discharge for the same condition or related symptoms, submit a single bill or a corrected bill that combines both admissions into one claim.

Risk of separate claimsIf two separate claims are filed for same-day readmission, the claims processing system may apply a systematic denial.

Leave of absence optionIf a patient is placed on a documented leave of absence instead of discharging and readmitting for known follow-up or elective surgery, submit a claim including the leave of absence so it does not result in two claims or payments.

Reimbursement & Claims Submission Requirements

Billing Rule

Reimbursement and Claims Submission Requirements

Florida Blue will not provide additional reimbursement for related subsequent admissions found to be reasonably preventable after clinical review; hospitals remain financially liable and may not bill the member for such preventable readmissions. When a readmission occurs on the same day as discharge for the same condition or related symptoms, hospitals must submit a single bill or a corrected bill combining both admissions to avoid a systematic denial.

Hospitals must not bill members for subsequent admissions determined to be preventable (member liability = $0).
If readmitted the same day for the same condition, submit a single claim or a corrected claim combining both admissions.
Filing two separate claims for same-day readmission may trigger a systematic denial by claims processing.

Key Definitions

Preventable readmission — definition

DefinitionPreventable readmission: a subsequent admission occurring less than 15 days from a prior discharge to the same hospital or a satellite of the hospital, or a return transfer from a sub-acute facility to the originating hospital or satellite.

Day counting ruleWhen determining the number of days between admissions, neither the day of discharge nor the day of readmission is counted.

ScopeApplies to contracted hospitals and to subsequent admissions reviewed for relation to the prior admission and reasonable preventability by clinical review.

Financial responsibility

Hospital financial liabilityInpatient stays not approved for additional reimbursement under this Readmission Policy will be the sole liability of the hospital.

Member financial protectionFlorida Blue members are not to be held liable for subsequent admissions determined to be preventable; hospitals are not allowed to bill members for the preventable readmission.

Reimbursement consequenceCompensation for the original admission constitutes the full reimbursement payable for both the original admission and the preventable readmission; additional reimbursement will not be provided.