Contracted Rates & Claim Submissions

Policy

1. Participating providers with Horizon BCBSNJ will not be held to contracted rates/terms for providing services, which are excluded under a member’s plan. Therefore, providers may bill their usual and customary charges to members for such services.
2. Participating providers with Horizon BCBSNJ will be held to contracted rates/terms for providing covered services under a member’s plan. Therefore, providers may not balance bill members to providers’ contracted rates for such services.

These covered services in “B” include, but are not limited to:

• Services alternated from another service by Horizon BCBSNJ
• A service for which a member reaches his or her annual dollar maximum because of the service
• Services for which providers receive no reimbursement by Horizon BCBSNJ because the member exceeded their annual dollar maximum
• Services for which associated claims are processed through the medical claims system rather than the dental claims system

Claim Submissions

Only submit a claim for reimbursement when services have been completed (e.g., denture or crown has been inserted). Horizon BCBSNJ views claim submission prior to the completion of the service as fraudulent practice.

Claims can be submitted via EDI submissions or paper claim submissions. Reimbursement is usually prompt when claims are submitted via EDI.

Horizon BCBSNJ’s electronic payor ID is 22099.

Mail paper claim submissions to:

We will process your claims and send you reimbursement for all eligible services. An Explanation of Benefits (EOB) will be sent to you outlining patient liability. In some cases, we may reimburse our full allowance; however, some services or products may require a copayment, or be subject to a deductible or coinsurance.

If your patient asks for a copy of his/her bill, please explain that you will file the claim with Horizon BCBSNJ first. We hope to discourage patients from sending claims that you have already submitted. This will help us avoid processing the same claim twice and generating two notifications, confusing your office and the member.

Helpful Hints for Claim Submissions:

To help ensure prompt and accurate processing of your claims:

• Ask for the member’s ID card at each visit to have the most current enrollment information available. Always photocopy or scan both sides of the member ID card for your files.
• Don’t confuse the subscriber with your patient. The patient is the person you treat. Complete the patient information on your claim as it relates to the person being treated.
• Use the subscriber’s and/or patient’s full name. Avoid nicknames or initials.
• Include the patient’s date of birth.
• Claims must include the entire member ID number.
• If a group number appears on the member’s ID card, please include it on the claim form.
• Clearly itemize your charge(s) and date(s) of service.
• Include the treating provider information as it is listed in Horizon BCBSNJ’s claims database. Please submit the Office/Provider Change Form if you need to update demographic information.
• Use accurate and specific CDT codes.

Predetermination Requests

Predetermination can be useful for both the patient and dentist. Predetermination helps each person understand which services will be covered under the patient’s contract, how much will be paid by Horizon BCBSNJ and the financial responsibility of the patient before treatment begins.

Predeterminations are suggested for major services, such as fixed and removable partial dentures, inlays/onlays and crowns, and periodontal procedures. However, if there is ever any question as to coverage of a procedure, a predetermination is recommended.

To file a predetermination, submit a request/claim via your usual submission (EDI or paper) including all anticipated services and their appropriate CDT codes.

Predeterminations are generally valid for 12 months from date of issuance. Predeterminations are approved and subject to continued patient eligibility and may be affected by unsatisfied deductible amounts, changes in remaining benefit maximum, benefit changes, policy changes and other insurance liability.

National Electronic Attachment, Inc. (NEA)

Horizon Dental offers the convenience of electronically submitting X-rays, narratives, Coordination of Benefit (COB) information or any supporting documentation via National Electronic Attachment, Inc. (NEA). For additional information, please call NEA at 1-800-782-5150 or visit their website at nea-fast.com.