Readmission Quality Program

Policy Number: GP-I-002

Last Updated: Oct. 6, 2022 

When a claim is received that indicates it is a readmission for a patient to the same facility, with the same or similar diagnosis, within 14 days of the original admission discharge date, both the original and readmission claims will be reviewed by Blue Cross and Blue Shield of Nebraska’s medical staff. If it is determined that the readmission is for the same or similar diagnosis or a complication of the initial admission, we will reimburse either the initial admission OR the subsequent readmission, whichever is the greater amount. The claim that is determined to be reimbursable will be reimbursed according to the terms of the patient’s contract. Decisions can be appealed through the normal appeal procedures.  

Readmissions related to the following diagnoses will NOT be part of the Readmission Quality Program:

  • Maternity 
  • Cancer  
  • Transplants  
  • Behavioral health  

This policy is intended to increase the quality of care for our members through encouraging a greater emphasis on care coordination and discharge planning. With a decrease in repeat admissions the patient’s risk for complications and poor outcomes decreases.