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Cost Sharing on Claims with Multiple Diagnoses

Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) previously announced the waiver of member cost-sharing obligations for covered benefits associated with treatment of COVID-19.

Beginning with dates of service on and after July 15, 2020, this cost-share waiver is only in effect for services when the primary diagnosis is COVID-19. Specifically:

  • Inpatient/Facility claims will not have member cost sharing if the primary diagnosis is U07.1.
  • Outpatient claims will not have member cost sharing if the primary diagnosis is U07.1, Z03.818 or Z20.828.

Cost sharing is waived only for in-network claims and for out-of-network admissions originating from the Emergency Room.

Claims submitted with any other primary diagnosis will be processed according to the member’s benefits and normal cost sharing will apply.

This change applies to fully insured members including those covered by Medicare Advantage, and Individual and Small Group policies. Self-insured health plans are responsible for the specific plan designs they choose to offer to their employees, and Horizon BCBSNJ will continue to work with them to administer their plan designs as directed.