Claims Issue Identified: Pay Percent for Multiple Services Rules

On June 3, 2018, Horizon Blue Cross Blue Shield of New Jersey implemented reimbursement policy guidelines that changed the way we reimburse claims for certain multiple services (i.e., diagnostic cardiovascular services, diagnostic ophthalmology services and professional therapy services1) when rendered by the same health care professional on the same date of service.

We are aware of a claim processing system issue that is resulting in the inappropriate application of these guidelines to claims for services rendered between February 4, 2018 and June 2, 2018. As previously announced, the application of these guidelines should be effective for services rendered on and after June 3, 2018.

We are currently addressing this issue and expect to have it corrected on or around July 1, 2018.

We will temporarily suspend the application of these reimbursement guidelines to claims while we address this issue. We will not carry out bulk adjustments of claims finalized during the time that these rules are suspended; however, if finalized claims are adjusted for other reasons, these reimbursement guidelines will be applied.

Following the system correction, Horizon BCBSNJ will identify and adjust impacted claims for services rendered between February 4, 2018 and June 2, 2018 to ensure appropriate reimbursement.

There is no need to submit claim appeals or to resubmit claims.

Thank you for your patience as we work to correct this issue.

¹ Horizon BCBSNJ only applies Multiple Procedure Payment Reduction (MPPR) guidelines to therapy services rendered by nonparticipating practitioners. MPPR guidelines on therapy services will NOT apply to therapy services rendered by participating practitioners.

Published on: June 21, 2018, 16:58 PM ET
Last updated on: June 21, 2018, 16:59 PM ET