Claim Adjustment Notification: Correct Coding/Code-Editing Guidelines

On October 11, 2019, Horizon BCBSNJ will begin adjusting certain professional claims processed between July 1, 2018 and February 25, 2019 to ensure 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).

Review the list of claim-processing guidelines that will be addressed by claim adjustments to be conducted beginning October 11, 2019.

These actions are part of a larger Horizon BCBSNJ effort to ensure that claims identified during the course of recent audits are processed in accordance with nationally recognized coding and code-editing guidelines. Previous announcements related to this effort were posted to HorizonBlue.com/providernews on September 14, 2017, January 5, 2018 and September 21, 2018.

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.

If you have any questions, call Physician Services at 1-800-624-1110, Monday through Friday, between 8 a.m. and 5 p.m., Eastern Time.

CPT® is a registered mark of the American Medical Association.