The Importance of Accurate Claim Coding

To help ensure you receive accurate reimbursement, use the most accurate and current codes, and follow the most current and appropriate billing practices, rules and guidelines.

We encourage all health care professionals, facilities and ancillary providers and their billing offices and vendors to continue to work to ensure a high-level of accuracy and compliance with the most current and appropriate billing practices, rules and guidelines.

When you submit the most accurate and current codes, Horizon BCBSNJ is able to quickly and efficiently process claims and generate accurate and appropriate reimbursement for the health care services you provide to our members.

Horizon Blue Cross Blue Shield of New Jersey continually works to ensure that our code and claim-editing rules are up-to-date with standard business practices; that any changes/updates we make are conveyed in a timely manner; and that code- and claim-editing rules are fully and correctly implemented within our claim processing systems.

While Horizon BCBSNJ strives to achieve high levels of claim processing accuracy, there are times when we must correct how certain codes/claims have been processed/reimbursed based on errors or system malfunctions. Horizon BCBSNJ carefully considers the ways such claim adjustments impact the health care professional community and our members, and complies with all New Jersey Department of Banking and Insurance rules and regulations in regard to adjusting previously-processed claims.

QUARTERLY CLAIM EDITING UPDATES

Horizon BCBSNJ works to ensure that our code- and claim-editing rules are accurate and consistent with standard business practices, enabling us to process claims efficiently and provide accurate reimbursement for claims submitted for services provided to our members.

• We work with nationally-recognized vendors to implement quarterly claim-editing updates to help ensure that the coding within our claims processing system is appropriate and supported. Updates we make to our code- and claim-editing rules may reflect:
   
  • Rules/guidelines implemented by the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI), Outpatient Code Editor (OCE), American Medical Association (AMA) Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases Clinical Modification (ICD-CM).
     
  • The recommendations of various medical societies and organizations, medical policy and literature, research and standards, and input from academic affiliations as analyzed and compiled by business partners working on our behalf.
     
  • The implementation of new and/or revised Horizon BCBSNJ administrative, reimbursement and/or medical policies.
     
• On or around the beginning of each quarter, we post an announcement in our News and Legal Notices section that identifies the claim-editing updates we will implement.
   
• We make our Medical Policies, Administrative Policies, Reimbursement Policies and Guidelines and information about our Claim Editing Policies available on our Medical Policy Manual.

Thank you for your continued cooperation and for all you do to ensure a high level of accuracy and compliance.

CPT® is a registered mark of the American Medical Association.