Claim Editing Issue Update: Claims to be Adjusted

As previously announced, a claim processing system issue resulted in the inappropriate application of claim editing rules to codes included on certain professional claims processed between March 1, 2018 and April 17, 2018.

Beginning on July 16, 2018, Horizon BCBSNJ will begin to adjust claims impacted by this system issue to either:

  • Appropriately apply claim editing rules to codes included on certain professional claims where they were not originally applied, or
  • Remove the application of claim editing rules to codes included on certain professional claims where they should not have been originally applied.

Changes to reimbursement and to patients’ financial responsibility for these impacted claims will be documented in the Explanation of Payment (EOP) statements you will receive following the completion of each claim adjustment as well as in the revised members’ Explanation of Benefits (EOB) statements.

Any reimbursement recoveries that may result from claim adjustments will establish Accounts Receivables (A/Rs) in our claim system. A/Rs are inactive for a period of 45 days to allow time for the return of overpayments to us or for an appeal to be filed with us. After 45 days, pending A/Rs will be activated and begin applying against future payments toward satisfying the A/R amount.

We apologize for any inconvenience.

Published on: June 14, 2018, 13:35 PM ET
Last updated on: June 14, 2018, 13:36 PM ET