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2020 Quarterly Claim Editing Updates

For 2020, Horizon BCBSNJ will continue our practice of implementing quarterly updates to our systems to help ensure that our code and claim editing rules are consistent with standard business practice and that reimbursements we make are accurate and appropriate.¹

We will continue to announce upcoming quarterly code and claim editing rules updates providing no less than 30 days’ notice. The effective dates of quarterly changes will reflect the first day of each respective quarter (i.e., January 1, April 1, July 1, October 1).²

  • On the first day of each quarter, we will implement claim editing updates related to rules/guidelines implemented by the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) that will impact claims for services provided to patients enrolled in fully insured, Medicare Advantage, and State Health Benefits Program/School Employees’ Health Benefits Program (SHBP/SEHBP) plans.

    Details of these updates may be accessed by visiting CMS web pages Quarterly PTP and MUE Version Update Changes and PTP Coding Edits.

  • Additional quarterly claim editing updates (including the NCCI edits noted above for all other members) will be implemented according to the schedule noted below (but may be subject to change):

    Q1 edits will be implemented into our systems on or about February 1, 2020

    Q2 edits will be implemented into our systems on or about May 1, 2020

    Q3 edits will be implemented into our systems on or about August 1, 2020

    Q4 edits will be implemented into our systems on or about November 1, 2020

Within our claim processing systems, the effective dates of these quarterly changes will reflect the first day of each respective quarter.²

Claims for services provided on and after the first day of a quarter that are processed prior to an announced implementation date will not reflect the quarterly changes announced. Horizon BCBSNJ will NOT seek to adjust claims for services provided on and after the first day of a quarter that are processed prior to an announced implementation date.

However, if a claim is adjusted following the implementation date of a quarterly update, and the claim is for a service provided on or after the first day of a quarter that was finalized prior to an announced implementation date, the claim will be processed based on the code and claim editing rules for that quarter.

MAC NOTIFICATION POLICY REMINDER
Horizon BCBSNJ will continue to provide 90 days’ advance notice for the implementation of new and/or revised Horizon BCBSNJ administrative, medical and/or reimbursement policies that result in a material adverse change as outlined in our Material Adverse Change (MAC) Notification Policy.

To access this administrative policy, log in to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu and:

  • Mouse over References and Resources and click Provider Reference Materials
  • Mouse over Policies & Procedures and click Policies
  • Click Administrative Policies

If you have questions, please call Physician Services at 1-800-624-1110 or Institutional Services at 1-888-666-2535, Monday through Friday, between 8 a.m. and 5 p.m., Eastern Time.

¹ We implement quarterly updates to help ensure that claims are processed using new and revised Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes, and that our claim editing rules and practices reflect the most current coding and code editing guidelines of nationally recognized sources including the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI), Outpatient Code Editor (OCE), and International Classification of Diseases Clinical Modification (ICD-CM).

² Codes may periodically be added to or deleted from our code auditing software and are not considered changes to the software version. In some cases, CMS may implement changes with an effective date prior to the first day of the quarter. Horizon BCBSNJ will not change or revise those industry-standard dates


CLEAR CLAIM CONNECTION
You can review how updated claim editing rules impact reimbursement for certain code combinations by using Change Healthcare’s Clear Claim Connection tool available via NaviNet®.

To access Clear Claim Connection:

  • Log in to NaviNet.netand select Horizon BCBSNJ from the My Health Plans menu
  • Mouse over Claim Management and click Clear Claim Connection

Horizon BCBSNJ makes our Medical Policies, Administrative Policies, Reimbursement Policies and Guidelines and information about our Claim Editing Policies available on HorizonBlue.com/policies.

CPT® is a registered mark of the American Medical Association.
NaviNet® is a registered trademark of NaviNet, Inc.

Published on: December 2, 2019, 00:15 AM ET
Last updated on: December 2, 2019, 01:58 AM ET