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Documentation Request Reimbursement Policies to be Implemented

Effective February 15, 2021 and based on the guidelines of the reimbursement policies below, Horizon BCBSNJ will change how we process and reimburse certain hospital claims for which a request for medical record documentation has been made.

  • Pre-Payment Documentation Requests for Facility Claims
  • Post-Payment Documentation Requests for Facility Claims

Per the guidelines of these policies, Horizon BCBSNJ network hospitals must provide documentation (including but not limited to itemized bills and medical record information) within 30 days of a request by Horizon BCBSNJ or one of our designees working on our behalf for information pertaining to claims identified for pre- or post-payment audit or review.

Applicable types of claim reviews include, but are not limited to:

  • Validation of the correct diagnosis related group (DRG) assignment/payment (DRG validation audits)
  • Validation that items and services billed are properly documented in:
    1. The medical record and/or
    2. An itemized bill for hospital bill audits, and in either case are items that are eligible to be separately billed
  • Verification that services billed do not conflict with eligible benefits for covered persons
  • Services billed that are reimbursable at a percent of invoiced amount

Please comply with our requests for documentation
If the requested documentation is not received within 30 days of the request, Horizon BCBSNJ may deny claims or adjust previously finalized claims to initiate a full or partial recovery of amounts reimbursed until such time that the requested information can be received and reviewed.

The guidelines of these policies apply to claims for services rendered to patients enrolled in fully insured commercial plans, Medicare Advantage plans and New Jersey State Health Benefits Program/School Employees’ Health Benefits Program (SHBP/SEHBP) plans. Horizon BCBSNJ network hospitals may not seek payment from our members for services denied for such reasons.

Published on: November 2, 2020, 04:37 a.m. ET
Last updated on: November 2, 2020, 04:39 a.m. ET