Posted June 4, 2021
Blue Cross and Blue Shield of Illinois (BCBSIL) conducts readmission review of hospital services provided to our Blue Cross Community Health PlansSM (BCCHP) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members. If you submit claims to BCBSIL for these members, please review the important reminder information below.
BCBSIL reviews all subsequent hospital admission claims within the specified timeframe governed by Illinois law, the applicable regulations, and/or requirements set forth in Illinois Medicaid contracts. This process consists of assessing all subsequent hospital admissions that occurred within 30 days of the previous discharge date and determining whether each individual subsequent hospital admission is to be classified as a readmission for the same facility or hospital system.
30-day Readmission Review Process Exception Criteria
If BCBSIL receives a claim for a subsequent hospital admission that BCBSIL determines is a readmission, BCBSIL will deny such claim unless one of the exception criteria on the list below, established by the Illinois Department of Healthcare and Family Services (HFS), is met:
- The readmission is determined to be due to an unrelated condition from the first inpatient admission and there is no evidence that premature discharge or inadequate discharge planning in the first admission necessitated the second admission;
- The readmission is part of a planned medically necessary, prior authorized or staged treatment plan;
- There is clear medical record documentation that the patient left the hospital against medical advice during the first hospitalization prior to completion of treatment and discharge planning;
- Long term care and/or skilled nursing facility (SNF) for custodial stays;
- Psychiatric and rehabilitation hospital care;
- Metastatic malignancy;
- Multiple traumas;
- Neonatal and obstetrical services;
- Sickle cell anemia;
- Certain HIV Diagnosis Related Groupers (DRGs);
- Alcohol or drug detoxification;
- Behavioral health-related primary diagnosis at discharge;
- Post-acute admission to a SNF, Inpatient Rehabilitation Facility (IRF) or Long-Term Acute Care Hospital (LTACH); or
- Transfer from one acute care hospital to another.
Always check eligibility and benefits through the Availity® Provider Portal or your preferred web vendor prior to rendering care and services to BCBSIL members. This step will confirm membership status, coverage details and prior authorization requirements.1
How to request prior authorization: Prior authorization requests may be made by phone (call 877-860-2837 for BCCHP members, call 877-723-7702 for MMAI members) or by fax to 312-233-4060 (same fax number for BCCHP and MMAI). Prior authorization requests for administrative days (ADs) may not be submitted online at this time.
1Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, call the number on the member’s ID card.
Disclaimer: The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.