Claim Adjustment Notification: Correct Coding/Code-Editing Guidelines
A recent audit of our claim-processing system revealed that certain claims were not processed in accordance with nationally-recognized coding and code-editing guidelines.
Beginning September 14, 2017, Horizon Blue Cross Blue Shield of New Jersey will begin adjusting certain professional claims1 processed between April 1, 2016 and March 31, 2017 to ensure that the procedure codes submitted are processed in accordance with nationally-recognized coding and code-editing guidelines. This includes guidelines implemented by the Centers for Medicare & Medicaid Services (CMS), National Correct Coding Initiative (NCCI), Outpatient Code Editor (OCE), American Medical Association (AMA), Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS) and the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM).
Reimbursement details, including any changes to member cost sharing responsibility, will be included in the Explanation of Payment statement(s) and member Explanation of Benefits statement(s) we will generate following the completion of each claim adjustment.
We apologize for this inconvenience.
If you have questions, please call Physician Services at 1-800-624-1110 or the Centralized Service Center at
1-888-666-2535, Monday through Friday, between 8 a.m. and 5 p.m., Eastern Time.
1 The initial population of claims to be adjusted beginning September 14, 2017 are for services rendered by nonparticipating practices. The adjustment of claims for services rendered by participating practices will be adjusted following a period of no less than 30 days from this announcement.
2 The correct coding claim adjustment effort being announced here is part of a larger effort to address/correct claims that were not processed in accordance with nationally-recognized coding and code-editing guidelines. Additional notices will be posted in the future to advise of additional claim adjustment efforts to be conducted.