HMS to Perform Claim Review for SHBP/SEHBP Plans

The New Jersey Division of Pensions and Benefits has authorized a review of health care claims submitted to Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) for members of the State Health Benefits Program and School Employees’ Health Benefits Program (SHBP/SEHBP). The state has contracted with Health Management Systems, Inc. (HMS) to conduct ongoing reviews of health care claims to ensure the integrity of the claims. The review will include coding validation, billing accuracy and compliance with regulations, policies, contractual requirements and utilization standards.

Beginning January 1, 2021, HMS will select claims for review and will contact you if any additional information is required. Both pre- and post-payment claims will be reviewed and the result may alter the payment of the claim.

Your prompt response to requests from HMS, on behalf of the SHBP/SEHBP and Horizon BCBSNJ, for medical records or supporting documentation, is appreciated. During the review process, all questions should be directed to HMS. If you fail to respond by the deadline noted in the request, Horizon BCBSNJ reserves the right to deny claims payment on behalf of SHBP/SEHBP.

If you are dissatisfied with the decision by HMS on specific claims, you have the right to request an inquiry, first through HMS and then Horizon BCBSNJ.