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Electronic Claim Adjustment Requests

Horizon BCBSNJ recommends that claim adjustment requests be sent electronically via standard HIPAA 837 transaction sets. We accept electronic claim adjustment requests for professional (837P) and institutional (837I) claims.

Recently completed system enhancements allow us to address your electronic adjustment requests more quickly, speeding our adjudication and payment to you.

You may electronically submit any adjustments that do NOT require the submission of additional supporting documentation, such as medical records, for:

  • Local professional, institutional and dental claims, including State Health Benefits Program.
  • Federal Employee Program® professional, institutional and dental claims.
  • BlueCard® professional and institutional claims. Note: BlueCard® claim adjustment requests to change the subscriber ID, provider Tax ID Number or provider suffix cannot be submitted electronically. Please submit these requests by mail.

Contact your vendor or clearinghouse for information about 837 transactions. Most clearinghouses already send us 837 transactions and can work with you to submit adjustment requests in the appropriate format.

If you have questions, please contact the Horizon BCBSNJ eService Desk at 1-888-334-9242 or email: Representatives are available Monday through Friday from 7 a.m. to 6 p.m., Eastern Time.

How to Indicate Your 837 Transaction Is an Adjustment Request

To indicate the electronic transaction you’re submitting is an adjustment request, include the following required information within your electronic 837 transaction:

Frequency Code

The appropriate Frequency Code must be present on your 837 transaction to indicate the information being submitted is for a claim adjustment.

  • Institutional claim adjustment submissions: the third position of the Type of Bill (values 5, 7, 8, F, G, H, I, J, K, M or N) indicates this transaction is an adjustment.
  • Professional and dental claim adjustment submissions: the Frequency Code (values 7 or 8) associated with the Place of Service indicates this transaction is an adjustment.

Claim Note

Professional and dental claim electronic adjustment requests must include the Adjustment Reason and Narrative explaining why the claim is being adjusted. (Example: Adjustment Reason: Number of units; Narrative: Units billed incorrectly, changed units from 010 to 001.)

Billing Note

Institutional claim electronic adjustment requests must include the Adjustment Reason and Narrative explaining why the claim is being adjusted. (Example: Adjustment Reason: Subscriber ID corrections; Narrative: Transposed subscriber ID, correct Sub ID is 12345678 for John Smith, DOB 11-22-1970.)

Original Reference Number

All 837 electronic adjustment transactions must include the claim number of the originally adjudicated claim found on your remittance advice (i.e., the ICN/DCN of the claim you want adjusted).

The Original Reference Number (ORN) submitted on the electronic adjustment can be found on the 835-remittance advice referenced by Claim Payment Information qualifier – CLP07 or the original claim number on your Explanation of Payment (EOP). The ORN is the only number that should be sent as the original adjudicated claim.

Original Claim Remittance Advice Resubmitted Claim Secondary Claim
2003 REF (F8) Not Used 2100 | CLP07 2300 | REF (F8) Not Used

Please share this information with your vendor or clearinghouse to ensure your electronic transactions are being submitted correctly.

BlueCard® and Federal Employee Program® (FEP®) are registered marks of the Blue Cross and Blue Shield Association.

Published on: September 26, 2022, 12:02 p.m. ET
Last updated on: September 23, 2022, 09:23 a.m. ET