Readmission dispute process

As posted in July 2022, in alignment with CMS and the National Quality Forum (NQF), as of September 30, 2022, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) does not allow separate reimbursement for inpatient admissions identified as at readmission.

Providers will receive notification when a readmission is identified through the prior authorization or post-service claim review process. This decision is not eligible for appeal, however providers may submit a dispute using the form on the Forms & Documentation page.

Please expect approximately a 30-day review timeline from receipt of form.

This process applies to all Commercial, Administrative Services Only (ASO), Blue Medicare, Experience Health, and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This process does not apply to Blue Cross NC members who seek care in other states.

Policies are available using the links below:
Commercial Policy (PDF)
Medicare Policy (PDF)

Contractual language and exceptions will supersede this policy criteria.