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

Effective June 26, 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 June 26, 2017, Horizon BCBSNJ will process claims submitted for services provided on and after June 26, 2017 to Horizon BCBSNJ MA members following the guidelines set forth in the National Coverage Determinations (NCD), Local Coverage Determinations (LCD) and/or their supporting articles listed in the tables below.

NCD/Supporting NCD Article Title NCD/Article Document ID
Bladder Stimulators (Pacemakers) 230.16
Melodic Intonation Therapy 170.2
Sleep Testing for Obstructive Sleep Apnea (OSA) 240.4.1
Bariatric Surgery for Treatment of Morbid Obesity 100.1


LCD/Supporting LCD Article Title LCD/Article Document ID
Allergen Immunotherapy L36240
Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device) A55240
Autonomic Function Tests L35395
Bariatric Surgical Management of Morbid Obesity L35022
Barium Swallow Studies, Modified L35433
Biomarkers for Oncology L35396
Biomarkers Overview L35062
Cardiac Event Detection Monitoring L34953
Cardiac Rhythm Device Evaluation L34833
Controlled Substance Monitoring and Drugs of Abuse Testing L35006
Corus® CAD Test L36713
Cosmetic and Reconstructive Surgery L35090
C-Reactive Protein High Sensitivity Testing (hsCRP) L34856
Flow Cytometry L35032
Frequency of Dialysis L35014
Implantable Infusion Pump L35112
In Vitro Chemosensitivity & Chemoresistance Assays L36634
Infrared Photocoagulation (IRC) of Hemorrhoids L34861
Intraoperative Neurophysiological Testing L35003
Lacrimal Punctum Plugs L35095
Lower Extremity Major Joint Replacement (Hip and Knee) L36007
Microvascular Therapy L36434
Mohs Micrographic Surgery (MMS) L34961
Molecular Diagnostics: Genitourinary Infectious Disease Testing L35015
NCD on Pneumatic Compression Therapy A53133
Nerve Conduction Studies and Electromyography L35081
Neurophysiology Evoked Potentials (NEPs) L34975
Oral Maxillofacial Prosthesis L35047
Outpatient Sleep Studies L35050
Outpatient Wireless Pulmonary Artery Pressure Monitoring for Heart Failure L36419
Pain Management of Peripheral Nerves by Injection L35107
Prostate Mapping Biopsy L35009
Real-Time, Outpatient Cardiac Telemetry L34997
Routine Foot Care L35138
Sacral Nerve Stimulation L35449
Scanning Computerized Ophthalmic Diagnostic Imaging L35038
Single Chamber and Dual Chamber Permanent Cardiac Pacemakers - Coding and Billing A54982
Speech-Language Pathology (SLP) Services: Communication Disorders L35070
Strapping L36423
Surgery: Blepharoplasty L35004
Surgical Treatment of Nails L34887
Therapy and Rehabilitation Services (PT, OT) L35036
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography L35035
Transesophageal Echocardiography (TEE) L35016
Transoral Incisionless Fundoplication L34999
Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities L34924
Wireless Capsule Endoscopy L35089

Please note: The implementation of claim edits related to the LCDs/NCDs noted here is part of a larger Horizon BCBSNJ effort to implement all NCD and LCD guidelines for MA plans, originally announced on November 7, 2016. Additional notices will be sent 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 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
  4. Scroll down and click the LCD Title in question.
  5. Review the LCD Information that is displayed.
Published on: May 24, 2017, 10:39 a.m. ET
Last updated on: May 24, 2017, 11:14 a.m. ET