CurrentPremera BluecrossPolicy N/A

Hospital or Hospital System Readmissions — Reimbursement Criteria and Exceptions

Governs identification and processing of acute care inpatient readmission claims to the same hospital or hospital system for Premera Blue Cross and affiliated lines of business; affects facility inpatient claims and providers submitting UB-04/837I claims.

Policy Summary

PayerPremera Bluecross

PolicyHospital or Hospital System Readmissions — Reimbursement Criteria and Exceptions

Policy CodePolicy N/A

Change TypeRevised definitionsadded coding requirementsclarified exceptions

Effective DateSept 5, 2025

Next Review DateN/A

Key ActionEnsure correct Discharge Status on initial claim and correct Admission Status on readmission claim to identify same-day transfers and avoid readmission denials.

SourceLink

POLICY UPDATE CHANGES

Readmission period definition revised to 30 calendar days and same condition limited to same DRG; readmission claim may be denied for unplanned inpatient readmissions within 30 days.

Requirement to correctly identify same-day transfers using specific discharge and admission status codes to avoid readmission denial.

Exceptions/Excluded readmission types clarified and enumerated (e.g., planned chemo, burns, cystic fibrosis, pediatrics, behavioral health, transplant, newborns).

30 daysreadmission period (includes day of discharge as day 0)

Sept 5, 2025definitions & 30-day rule effective

May 8, 2026

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.

denial authority effective

UB-04 / 837Iapplies to claim forms

Multiple DRG listsexceptions reference

Readmission Reimbursement Criteria and Exceptions

Readmission reimbursement criteria and exceptions

Covered when ALL of the following criteria are met:

Admission is an acute care inpatient admission to the same hospital or hospital system within the 30 calendar day readmission period (day of discharge = day 0).

The readmission is unplanned (not a scheduled admission or part of a known continued hospitalization cycle).

The readmission is for the same condition as treated in the original stay, where 'same condition' is determined by the same DRG.

If the readmission is clinically related to the prior admission (examples include surgical complications, follow-up care after prior admission, surgical site infections, ventilator‑associated pneumonia, catheter‑associated infections, venous thromboembolism after missed prophylaxis, or additional hospitalization due to lack of services/supplies during the first admission), the Plan may deny reimbursement for unplanned readmissions effective May 8, 2026.

Denial authority effective May 8, 2026.

Same‑day transfers must be correctly identified to avoid being treated as a readmission: the initial claim must include the appropriate Discharge Status code and the receiving facility's claim must include the appropriate Admission Status code as listed in the policy. Failure to correctly code same‑day transfers will result in the claim being considered a readmission and may be denied.

Discharge/Admission status codes are specified in the Codes/Coding Guidelines section.

Exceptions — readmissions that are NOT subject to readmission denial

Planned non‑surgical treatments (for example: chemotherapy and related regimens) with specified DRGs (54–55, 146–147, 180–182, 837–839, 846–848).
Burn care readmissions with specified DRGs (927–929, 933–935).
Cystic fibrosis readmissions (DRGs 177–179).
Transfusions for chronic anemias (e.g., sickle cell anemia).
Scheduled, planned, or delayed elective surgery readmissions.
Readmissions related to covered transplant services during the transplant global case rate period (including bone marrow and organ transplants) and tissue transplantation from live or cadaveric donor.

Coding Rules and Key Values

Discharge and Admission status codes for identifying same-day transfersmixed

02	Discharge/Transferred to Short-Term General Hospital for Inpatient care
05	Discharged/Transferred to Designated Cancer Center or Children's Hospital
07	Left Against Medical Advice or Discontinued care
20	Expired
30	Still a patient
81	Discharged to Home of Self-care with a planned acute care hospital inpatient readmission
82	Discharged/Transferred to Short Term General Hospital for inpatient care with a planned acute care hospital inpatient readmission
83	Discharged/Transferred to Skilled Nursing facility with Medicare certification with a planned acute care hospital inpatient readmission
84	Discharged/Transferred to a facility that provides custodial or supportive care with a planned acute care hospital inpatient readmission
85	Discharged/Transferred to a designated cancer center or Children's hospital with a planned acute care hospital inpatient readmission

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Readmission period (days)

Readmission lookback period30 calendar days (day of discharge = day 0; 0-30)

Effective date for 30-day definitionDefinitions and 30-day readmission rule effective September 5, 2025

Applies to claim formsUB-04 / 837I facility inpatient claims

Provider Billing Requirements and Denial Risk

Denial Risk

Potential denial for clinically related readmissions

Effective with claim dates of service on and after May 8, 2026, the plan may deny reimbursement of unplanned inpatient readmission claims for clinically related conditions within 30 calendar days of discharge from the same Hospital or Hospital System. Examples of clinically related conditions include, but are not limited to: surgical complications; follow-up care related to the prior admission; surgical site infections; pneumonia associated with ventilator services; catheter-associated urinary tract infections; catheter-associated bloodstream infections; venous thromboembolism after missed opportunity for prophylaxis; and additional hospitalization/readmission due to lack of available services or supplies during the first inpatient admission.

Effective date: May 8, 2026
Clinically related readmissions within 30 calendar days may be denied
Examples: surgical complications, surgical site infections, catheter-associated infections, pneumonia with ventilator services, VTE after missed prophylaxis, follow-up care related to prior admission

Key Definitions

Readmission / Same condition / Clinically Related

ReadmissionAn acute care inpatient admission that falls within 30 calendar days of a prior discharge from the same hospital or hospital system for the same or clinically related condition; same condition is determined by the same DRG.

Same conditionDetermined by the same diagnostic related group (DRG) classification as grouped by the diagnosis and procedure codes billed on a UB-04 or 837I claim for DRG reimbursed facilities.

Clinically related readmissionA readmission due to a condition that resulted from care or treatment received during a previous admission or follow-up care.

Hospital System

Hospital SystemTwo or more hospitals affiliated with, owned, or managed by a central organization.

Scope

Policy Summary

PayerPremera Bluecross

PolicyHospital or Hospital System Readmissions — Reimbursement Criteria and Exceptions

Policy CodePolicy N/A

Change TypeRevised definitionsadded coding requirementsclarified exceptions

Effective DateSept 5, 2025

Next Review DateN/A

Key ActionEnsure correct Discharge Status on initial claim and correct Admission Status on readmission claim to identify same-day transfers and avoid readmission denials.

SourceLink

On This Page

Pre‑delivery, obstetrical admissions and post‑partum complications (DRGs: 768–769, 770, 776, 779, 783–788, 796–798, 805–807, 817–819, 831–833).

Readmissions after an initial discharge against medical advice (AMA) when initial claim shows Discharge Status code 07 (Left Against Medical Advice) (DRG 894).

Behavioral health readmissions (psychiatric and substance use disorders) (DRGs 880–897).

Acute physical rehabilitation readmissions (DRGs 945–946).

Newborn/neonatal care readmissions and readmissions to children's hospitals or infants under 12 months of age (use patient age to exclude).

Pediatric oncology readmissions for patients under 18 years with specified DRGs (54–55, 146–147, 180–182, and 789–795).

Billing Rule

Same-day transfer coding requirement

Same-day transfers must be correctly identified to avoid readmission denials. A correct Discharge Status code on the initial hospital claim and the correct Admission (Point of Origin) code on the receiving facility claim are required to identify a claim as a "same day transfer" rather than a readmission. Failure to use the appropriate codes within a 24-hour transfer period will result in the claim being considered a readmission and may be denied reimbursement per policy.

Required Discharge Status codes on the initial claim include: 02, 05, 07, 20, 30, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95.
Required Admission (Point of Origin) codes on the receiving claim include: 4 (Transfer from a Hospital — different facility) and 6 (Transfer from another Healthcare Facility).
Identify same-day transfers within 24 hours of discharge using both the discharge and admission codes to prevent denials.

Applies to inpatient readmissions to the same hospital or hospital system for Premera and affiliated lines of business.

Use in determinationsReadmission determinations consider admissions to any hospital within the same system as the original discharge.

Same Day Transfer

Same Day Transfer definitionTransfers between acute care hospitals within any 24-hour period during the initial hospital stay, made via ambulance to access a higher level of care or care not available at the first facility.

Coding expectationInitial hospital claim must include an appropriate Discharge Status code and the receiving facility must include an appropriate Admission Status code to identify the same-day transfer.

PurposeProper coding avoids readmission determinations and potential denials for clinically related readmissions.

Unplanned readmission

Unplanned readmissionAn admission that was not scheduled and not a known readmission for a series of continued hospitalizations (e.g., inpatient cycles of inpatient chemotherapy).

Distinction from plannedPlanned readmissions (e.g., scheduled chemo, planned procedures) are listed as exceptions and are not considered unplanned.

Relevance to denialUnplanned inpatient readmissions for the same condition within 30 days may be denied reimbursement effective May 8, 2026 (per enforcement timeline).