Change Healthcare (CHC) Medical Injectable Drug Review Update

We previously announced that beginning January 22, 2021, Horizon BCBSNJ will collaborate with Change Healthcare (CHC) to review certain submitted claims/transactions related to the administration of medical injectable drugs. CHC will review the medical injectable drug dosage details and units administered, as well as Average Wholesale Price (AWP) information to ensure that claims are coded appropriately.

CHC’s request for medical record information regarding claims/transactions for services provided on and after January 22, 2021 include the codes/modifiers below:

• HCPCS codes J0120 though J9999, when appended with Modifier JW
• Facility revenue codes 250 to 0259 and/or 0631 to 0637

November update regarding HCPCS codes J0120 though J9999

Horizon BCBSNJ reserves the right to pend or deny a claim and request medical documentation to substantiate correct coding and documentation practices when a provider bills for HCPCS codes J0120 through J999 with modifier JW (indicating drug wastage).

For example, if a provider bills HCPCS code J0120 with modifier JW, the claim may be pended or denied and Horizon BCBSNJ may request records to substantiate appropriate documentation of drug wastage, correct vial size based on drug dosage, correct drug units (including validation of correct use of injection administration codes), type of injection, incidental hydration and time-based infusion codes.

Other audit details

CHC will request medical record information for claims/transactions submitted for services provided to patients enrolled in:

• Horizon BCBSNJ fully insured commercial plans
• Horizon BCBSNJ Medicare Advantage (MA) plans
• State Health Benefits Program/School Employees’ Health Benefits Program (SHBP/SEHBP) plans.

Claim lines that are not coded appropriately based on the medical record/AWP information will be denied.

We thank you in advance for your cooperation with CHC to review these claims on our behalf.

If you have any questions, call your Network Specialist at 1-800-624-1110 or an Institutional Services Representative at 1-888- 666-2535, weekdays, from 8 a.m. to 5 p.m., Eastern Time.