BLUE REVIEW^SM

December 2023

Reminder: Hospital 30-day Readmission Review Process for BCCHP^SM and MMAI Members

Blue Cross and Blue Shield of Illinois conducts readmission review of hospital services provided to our Blue Cross Community Health Plans^SM and Blue Cross Community MMAI^SM members. If you submit claims to BCBSIL for these members, please review the 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 assesses all subsequent hospital admissions that occurred within 30 days of the previous discharge date. It determines 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 and determines the claim is a readmission, BCBSIL will deny such claim unless one of the exception criteria on the list below is met. This list was established by the Illinois Department of Healthcare and Family Services:

• 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 for custodial stays;
• Psychiatric and rehabilitation hospital care;
• Metastatic malignancy;
• Multiple traumas;
• Burns;
• Neonatal and obstetrical services;
• Sickle cell anemia;
• Certain HIV Diagnosis Related Groupers;
• Alcohol or drug detoxification;
• Behavioral health-related primary diagnosis at discharge;
• Post-acute admission to a SNF, Inpatient Rehabilitation Facility or Long-Term Acute Care Hospital; or
• Transfer from one acute care hospital to another.

Always check eligibility and benefits through the Availity^® Essentials 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.

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 may not be submitted online at this time.