In an effort to identify clinically related readmissions to the same facility/network, licensed clinical staff with Anthem Blue Cross (Anthem) will review the clinical information submitted regarding the medical treatment and management of an Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) member admission that occurred within 2 to 30 days from a previous admission to the same facility/network. If the second admission is determined to be clinically related, Anthem will not reimburse for an additional admission as this is considered a continuation of the episode of care. This process was implemented June 2017.


Policy 13-001 update

Based on the information above, Anthem’s Inpatient Readmissions reimbursement policy has been updated. Anthem will utilize information indicating clinically related readmissions, clinical criteria and/or licensed clinical medical review for readmissions from day 2 to day 30 for the second admission determination. Please refer to the Inpatient Readmissions reimbursement policy at > Prior Authorization & Claims > MMP Reimbursement Policies for additional information.

Featured In:
October 2018 Anthem Blue Cross Provider Newsletter - California