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Claims to be Adjusted to Correct Certain Code Allowances

Horizon BCBSNJ recently identified and corrected a system issue that applied incorrect allowances on certain services/codes included on professional claims finalized between October 22, 2018 and November 12, 2018.

This issue prevented our system from applying the northern geographic region code for certain procedure codes included on professional claims processed for practitioners in northern New Jersey counties (i.e., Bergen, Essex, Hudson, Hunterdon, Middlesex, Mercer, Monmouth, Morris, Ocean, Passaic, Somerset, Sussex, Union and Warren).¹

The issue was corrected and has not affected claims finalized since November 12, 2018.

  • Beginning on or around February 22, 2019, Horizon BCBSNJ will begin to adjust impacted claims that were finalized between October 22, 2018 and November 12, 2018 to include the northern New Jersey geographic region as part of the criteria of determining the appropriate allowance.

Changes to reimbursement and to patients’ financial responsibility for these impacted claims will be documented in your Explanation of Payment (EOP) statements 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.

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

¹ Claims processed for services provided by professional providers in southern NJ counties (i.e., Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester and Salem counties) were not impacted by this system issue.

Published on: January 22, 2019, 12:57 p.m. ET
Last updated on: April 26, 2021, 02:31 a.m. ET