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Change Healthcare (CHC) to Perform Medical Injectable Drug Review

Effective 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.

This effort supports Horizon BCBSNJ’s commitment to ensuring consistency and appropriate reimbursement for services provided to our members. We appreciate your cooperation, especially during these uncertain times.

CHC may request medical record information in response to the submission of claims/transactions for services provided on and after January 22, 2021 that 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

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.

Published on: October 1, 2020, 05:10 a.m. ET
Last updated on: April 27, 2021, 03:06 a.m. ET