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Claim Processing Update re: New Patient E&M Codes

Effective July 22, 2022, Horizon will change how we process certain professional claims that include new patient Evaluation and Management (E&M) codes.

We recently conducted an extensive audit of how we process claims that include new patient E&M codes following the guidelines of the New Patient Evaluation and Management (E&M) Rule subsection of our ClaimsXten Editing Rules reimbursement policy.

  • Based on our policy guidelines, we deny a large number of new patient E&M codes because claims for professional services from either the rendering physician or from another physician of the same specialty who belongs to the same group practice within the previous three years are identified in claim history.
  • A majority of denied new patient E&M codes are subsequently adjusted following our receipt of corrected claim information that includes a more appropriate established patient E&M code.

Beginning July 22, 2022, our claim processing system – in addition to denying a submitted new patient E&M code that does not meet our new-patient criteria – will add and process a new claim line with an appropriate-level established patient E&M code.

Practices that disagree with our processing of any such claims, have the right to appeal.

This change will impact all claims processed July 22, 2022 and after, regardless of the date of service, for patients enrolled in:

  • Horizon fully insured commercial plans
  • Horizon Medicare Advantage plans
  • Braven Health℠ Medicare Advantage plans
  • Administrative Services Only group employer plans, including the New Jersey State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP)

We believe that this change will help improve your experience with our claim processing, save you the administrative effort and expense of submitting corrected claim information and allow our Service team representatives to spend less time manually reviewing and adjusting E&M claims more time addressing other issues for you.

If you have questions, please contact Physician Services at 1-800-664-4011.

Published on: June 20, 2022, 00:00 a.m. ET
Last updated on: June 16, 2022, 09:51 a.m. ET