CurrentPremera BluecrossPolicy N/A

Hospital or Hospital System Readmissions — Reimbursement Policy

Defines how the Plan identifies and processes acute care inpatient readmission claims to the same hospital or hospital system and when the Plan may deny reimbursement; applies to Premera Blue Cross and affiliated lines of business.

Policy Summary

PayerPremera Bluecross

PolicyHospital or Hospital System Readmissions — Reimbursement Policy

Policy CodePolicy N/A

Change TypeDefinitions revisedsame-day transfer coding addeddenial enforcement date added

Effective DateSept 5, 2025

Next Review DateN/A

Key ActionUse the correct Discharge Status on the initial claim and the correct Admission (Point of Origin) code on the receiving facility claim to identify same-day transfers and prevent readmission denials.

SourceLink

POLICY UPDATE CHANGES

Readmission definition and period revised to a 30-day readmission period and 'Same Condition' limited to same DRG.

Policy includes that same-day transfers must be correctly identified with specific Discharge Status and Admission codes to avoid being treated as readmissions.

Effective May 8, 2026 the Plan may deny reimbursement for unplanned inpatient readmissions for clinically related conditions within 30 days.

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

May 8, 2026effective date for denial of clinically related unplanned readmissions

Sept 5, 2025effective date for revised definitions/readmission period

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24 hourssame-day transfer window between hospitals to be treated as transfer, not readmission

MultipleDRG exclusions for planned treatments

Readmission Reimbursement Criteria

Readmission reimbursement criteria

The Plan may deny reimbursement for certain inpatient readmissions to the same hospital or hospital system when the following criteria are met:

Readmission occurs within the defined readmission window of 0–30 calendar days (day 0 = day of discharge).

Readmission is an unplanned inpatient admission (not a scheduled admission or part of a known series of continued hospitalization).

Readmission is for the same condition as treated in the original hospital or hospital system stay as determined by the same Diagnostic Related Group (DRG) classification on the facility claim.

Denial may be applied when any of the following is true:

The readmission is clinically related to the prior admission (examples include surgical complications, follow-up care after 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, or additional hospitalization due to lack of services/supplies during the first admission).
The readmission is not correctly identified as a same-day transfer between hospitals or hospital systems (transfers within any 24-hour period) because the initial claim does not contain an appropriate Discharge Status code and/or the receiving claim does not contain an appropriate Admission (Point of Origin) code. Failure to identify a same-day transfer will result in the claim being considered a readmission and may be denied.

Effective dates

Core rule (readmission definition and 30-day period) effective with claim dates of service on or after Sept 5, 2025.
Enforcement for clinically related unplanned readmissions: effective with claim dates of service on or after May 8, 2026, the Plan may deny reimbursement for clinically related unplanned inpatient readmissions within 30 calendar days.

DRG Exclusions, Codes, and Readmission Window

DRG-based exclusions and special groupsmixedNot Covered

DRG 54-55, 146-147, 180-182, 837-839, 846-848	Chemotherapy and related planned non-surgical treatments (excluded from readmission policy)
DRG 927-929, 933-935	Burns (excluded)
DRG 177-179	Cystic fibrosis (excluded)
DRG 768-769, 770, 776, 779, 783-788, 796-798, 805-807, 817-819, 831-833	Pre-delivery, obstetrical admissions and postpartum complications (excluded)
DRG 880-897	Behavioral health (psychiatric and substance use disorders) (excluded)
DRG 945-946	Acute physical rehabilitation readmissions (excluded)
DRG 894	Initial admission discharged AMA (excluded when discharge status code 07 present)
DRG 54-55, 146-147, 180-182, 789-795	Pediatric oncology exclusions (age criteria apply)

Discharge and Admission status codes required to identify same-day transfersmixed

02	Discharged/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 or Self-care with planned readmission
82	Discharged/Transferred to Short Term General Hospital with planned readmission
83	Discharged/Transferred to Skilled Nursing facility with planned readmission
84	Discharged/Transferred to custodial/supportive care with planned readmission
85	Discharged/Transferred to designated cancer center or Children's hospital with planned readmission

1–10 of 14

1/2

Readmission window

Readmission window0-30 calendar days (day 0 = day of discharge)

Includes day of dischargeDay 0 is the day of discharge; subsequent 30 calendar days follow

Effective date for revised periodEffective with claim dates of service on and after Sept 5, 2025

Billing, Transfer Identification, and Denial Risk

Documentation Required

Same‑day transfer identification requirement

Use the correct Discharge Status code on the initial hospital claim and the correct Admission (Point of Origin) code on the receiving facility claim to identify same-day transfers within 24 hours and prevent the transfer from being treated as a readmission. Failure to identify a same-day transfer with the appropriate Discharge Status and Admission codes will result in the claim being considered a readmission and may be denied reimbursement.

Initial claim must include an appropriate Discharge Status code (examples: 02, 05, 07, 20, 30, 81–86, 87–95 as noted in policy).
Receiving facility claim must include the correct Admission (Point of Origin) code (examples: 4 = Transfer from a Hospital (Different facility); 6 = Transfer from another Healthcare Facility).
Same-day transfers must occur within a 24-hour period from the discharge to be treated as a transfer rather than a readmission.

Denial Risk

Denial risk for clinically related readmissions (effective May 8, 2026)

Key Definitions

Readmission

Readmission (definition)An acute care inpatient admission within 30 calendar days of a prior acute care inpatient discharge from the same hospital or hospital system for the same or clinically related condition.

Applies toSame hospital or hospital system acute care inpatient admissions

PurposeUsed to identify claims that may be denied reimbursement under the Plan's readmission criteria

Same Condition

Same Condition (definition)Determined by the same diagnostic related group (DRG) classification as grouped by the diagnosis and procedure codes billed on the facility claim (UB-04/837I).

DRG basisLimited to DRG classification for DRG-reimbursed facilities per policy revision effective Sept 5, 2025

Policy Summary

PayerPremera Bluecross

PolicyHospital or Hospital System Readmissions — Reimbursement Policy

Policy CodePolicy N/A

Change TypeDefinitions revisedsame-day transfer coding addeddenial enforcement date added

Effective DateSept 5, 2025

Next Review DateN/A

SourceLink

On This Page

Effective with claim dates of service on and after May 8, 2026, the Plan may deny reimbursement for unplanned inpatient readmissions that are clinically related to a prior admission if they occur within 30 calendar days of discharge from the same Hospital or Hospital System.

Clinically related examples include surgical complications, follow-up care after the prior admission, surgical site infections, pneumonia associated with ventilator services, catheter‑associated infections, venous thromboembolism after missed prophylaxis, and hospitalizations due to lack of services/supplies during the first admission.

Use on claimDRG grouping is derived from diagnosis and procedure codes on the facility claim

Clinically Related Readmission

Clinically Related Readmission (definition)A readmission due to a condition that resulted from the care or treatment received during a previous admission or follow-up care (e.g., surgical complications, surgical site infections, catheter-associated infections, pneumonia related to ventilator services, venous thromboembolism after missed prophylaxis).

ExamplesIncludes surgical complications, follow-up care after prior admission, surgical site infections, catheter-associated urinary or bloodstream infections, ventilator-associated pneumonia, venous thromboembolism

EnforcementEffective May 8, 2026 the Plan may deny reimbursement for unplanned inpatient readmissions that are clinically related within 30 days.

Same Day Transfer

Same Day Transfer (definition)Transfers between acute care hospitals within any 24-hour period during the initial stay, typically via ambulance to a higher level of care.

Identification requirementsInitial claim must include an appropriate Discharge Status code and the receiving claim must include an appropriate Admission (Point of Origin) code to be treated as a same-day transfer rather than a readmission.

Timing ruleTransfer occurs within 24 hours of the initial hospital discharge to qualify as a same-day transfer

Unplanned readmission

Unplanned readmission (definition)An admission that was not scheduled and not part of a known series of continued hospitalization (e.g., inpatient cycles such as chemotherapy).

Exclusion notePlanned readmissions and known series of continued hospitalization are excluded from being treated as unplanned readmissions

Claim impactUnplanned status is a core criterion for potential denial under the readmission policy