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Notice to South Carolina Providers: Inpatient Readmission Payment Policy Updates
Act
by Jul 31, 2026
Effective date
Aug 1, 2026
Identified
Aug 11, 2026
Summary
Effective August 1, 2026, BlueCross BlueShield of South Carolina will deny separate reimbursement for inpatient readmissions occurring within 30 days of a prior admission when the readmission is for a clinically related, potentially preventable diagnosis. Billing teams must implement medical review processes and documentation requirements to identify readmissions that qualify for this bundled payment policy. Certain admissions (behavioral health, transplants, maternity/newborn, and facility transfers) are exempt from this policy.
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What to do
by Jul 31, 2026 · 8 steps
01Billing team must implement the following.
02Update billing system rules to flag inpatient claims submitted within 30 days of a prior inpatient admission for the same South Carolina BCBSSC member.
03Establish a medical review process to identify clinically related diagnoses that may be deemed potentially preventable readmissions.
04Communicate with clinical staff and providers to document clinical relationships between admissions and prevention efforts.
05Configure billing system to bundle flagged readmission claims or hold them pending BCBSSC medical review determination rather than billing separately.
06Train billing staff to recognize policy exceptions (behavioral health, transplants, maternity/newborn, facility transfers) and exempt those claims from the readmission review process.
07Review the complete Inpatient Hospital Readmission Policy on My Insurance Manager for detailed criteria and documentation requirements.
08Providers should be notified of potential claim denials for readmissions that do not meet exception criteria.
If missed: Failure to implement these controls will result in claim denials or recoupment of improperly paid readmission claims.
Original notice
Notice to South Carolina Providers: Inpatient Readmission Payment Policy Updates
southcarolinablues.com · Always check the source before changing claims.