See Changes to our Existing Inpatient Readmission Policy for Some Commercial Members

What’s changing?

We’re updating our existing Clinical Payment and Coding Policy 027 that utilizes guidance from the Centers for Medicare & Medicaid Services (CMS). Effective May 1, 2023 Blue Cross and Blue Shield of New Mexico (BCBSNM) will review acute hospital claims for some commercial members to determine if readmissions to the same facility within 30 days, or the number of days or terms specified in the provider contract, of discharge are clinically related.

The details

Under this existing and updated BCBSNM policy, reimbursement may be denied or reduced for an inpatient readmission if we determine the services rendered are considered a continuation of the initial treatment.

What should I expect?

If BCBSNM determines a provider has submitted a second claim within 30 days after a patient has been discharged from an acute inpatient stay, a post payment audit of the initial admission and subsequent readmission may occur.

Learn More

BCBSNM encourages you to read the entire updated Clinical Payment and Coding Policy CPCP027 located here.