Medicare Advantage Claim Editing Updates for LCDs

Effective September 1, 2018, 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 Centers for Medicare & Medicaid Services (CMS) guidelines.

Beginning on September 1, 2018, Horizon BCBSNJ will process claims submitted for services provided on and after September 1, 2018 to Horizon BCBSNJ members in MA plans following the guidelines set forth in the Local Coverage Determinations (LCDs) listed below.

You can review the details of these LCDs that may impact claims for services and/or supplies you provide to your patients enrolled in our MA plans. See below for instructions to access details through the CMS’ Medicare Coverage Database.

Horizon BCBSNJ is implementing claim edits related to the LCDs noted above as part of our larger effort to implement all National Coverage Determination (NCD) and LCD guidelines for MA plans. This was previously announced on November 7, 2016, May 24, 2017 and March 7, 2018. Impacted health care professionals will be notified of any additional edits that will be implemented.

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, 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 LCD details within the Medicare Coverage Database. Follow the instructions below to access this information.

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.