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Medical Policy Revision: Observation Care

Effective July 25, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for services provided to members in an observation status.

Our medical policy, Observation Care, identifies circumstances under which the treatment of a patient in an observation care status will be considered medically necessary. Please note that the guidelines of this policy shall not supersede observation care guidelines included as part of the a hospital's contract with Horizon BCBSNJ.

We encourage you to review this policy in our online Medical Policy Manual.

Based on the guidelines of our medical policy, Observation Care:

  • Professional claims submitted for services provided on and after July 25, 2016 that include CPT® codes 99224, 99225 and/or 99226 billed with three or more days/units in an observation care status will pend while information to help us determine if the service(s) in question are to be considered medically necessary is requested and reviewed.
  • Nonparticiapting facility* claims submitted for services provided on and after July 25, 2016 that include HCPCS code G0378 billed with 49 or more hours/units will pend while information to help us determine if the service(s) in question are to be considered medically necessary is requested and reviewed.
  • HCPCS code G0379 submitted on nonparticipating facility* claims for services provided on and after July 25, 2016 billed with two or more units will be denied as not medically necessary regardless of the diagnosis code(s) included.

*Participating Horizon Hospital Network facilities are excluded from the guidelines noted above based on their contractual agreements.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after July 25, 2016.

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

Published on: April 25, 2016, 08:00 a.m. ET
Last updated on: November 25, 2020, 00:21 a.m. ET