Skip to main content

Medicare Advantage Claim Editing Updates to be Implemented: NCDs and LCDs

Effective February 6, 2017, Horizon Blue Cross Blue Shield of New Jersey will implement updates to our claim editing rules and processes to help ensure that claims for members enrolled in our Medicare Advantage (MA) plans are processed according to standard Centers for Medicare & Medicaid Services (CMS) guidelines.

Beginning on February 6, 2017, Horizon BCBSNJ will process claims submitted for services provided on and after February 6, 2017 to Horizon BCBSNJ MA members following the guidelines set forth in the National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) listed in the tables below. Horizon intends to implement all NCD and LCD guidelines. Thus, additional notices will be sent in the near future advising of further batches of edits to be implemented.

NCD Title NCD Document ID
Biofeedback Therapy for the Treatment of Urinary Incontinence 30.1.1
Cardiac Pacemakers Single Chamber and Dual Chamber Permanent Cardiac Pacemakers 20.8.3
Colorectal Cancer Screening Tests 210.3
Computer Enhanced Perimetry 80.9
Endothelial Cell Photography 80.8
Percutaneous Image Guided Lumbar Decompression for Lumbar Spinal Stenosis 150.13
Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing Agents 150.7
Vagus Nerve Stimulation 160.18

 

LCD Title LCD Document ID
Ambulance Services (Ground Ambulance) L35162
Cataract Extraction (including Complex Cataract Surgery) L35091
Glaucoma Treatment with Aqueous Drainage Device L35087
Hydration Therapy L34960
Monitored Anesthesia Care (MAC) L35049
Non-Coronary Vascular Stents L35084
Non-Invasive Cerebrovascular Arterial Studies L35397
Non-Invasive Peripheral Venous Studies L35451
Pulmonary Function Testing L35360
Removal of Benign or Premalignant Skin Lesions L34938
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) L35350
Vestibular and Audiologic Function Studies L35007

Any member liability for services will be noted on the Explanation of Payment (EOP) and Explanation of Benefits (EOB) statements generated upon finalization of claims.

If you have questions, please call Physician Services at 1-800-624-1110, or Institutional Services at 1-888-666-2535, Monday through Friday, between 8 a.m. and 5 p.m., Eastern Time.


Medicare Coverage Database (MCD)
We encourage you to review the NCD and LCD details within the Medicare Coverage Database. Follow the instructions below to access this information.

To Access NCD information

  1. Access the Medicare Coverage Database
  2. Within the Quick Search section, enter the Document ID and click Search By ID.
  3. Scroll down and click the NCD Title in question.
  4. Review the NCD information that is displayed.

To Access LCD information

  1. Access the Medicare Coverage Database.
  2. Within the Quick Search section, enter the Document ID and click Search By ID.
  3. Enter a service date in the LCD Effective Date Search and click Search.
  4. Scroll down and click the LCD Title in question.
  5. Review the LCD Information that is displayed.
Published on: November 7, 2016, 06:00 a.m. ET
Last updated on: May 14, 2021, 09:20 a.m. ET