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Medicare Advantage Claim Editing Updates to be Implemented (LCDs and NCDs)

Effective April 9, 2018, Horizon Blue Cross Blue Shield of New Jersey will implement updates to our claim editing rules and processes. These updates will 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.

Claims submitted for services provided on and after April 9, 2018 to Horizon BCBSNJ MA members will be processed following the guidelines set forth in the National Coverage Determinations (NCD), Local Coverage Determinations (LCD) and/or their supporting articles identified here.

Providers are encouraged to review the NCD and LCD details within the Medicare Coverage Database which may be accessed by visiting the cms.gov Medicare Coverage-General Information webpage and following the instructions below.

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.

Please note: The implementation of claim edits related to the LCDs/NCDs addressed here is part of a larger Horizon BCBSNJ effort to implement all NCD and LCD guidelines for MA plans, announced in news items posted within the News and Legal Notices section of HorizonBlue.com on November 7, 2016 and May 25, 2017. Additional notices will be sent or posted in the future advising of additional edits to 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, please contact our Institutional Services team at 1-888-666-2535, Monday through Friday, between 8 a.m. and 5 p.m., Eastern Time.

Published on: March 7, 2018, 09:35 a.m. ET
Last updated on: March 7, 2018, 09:56 a.m. ET