Process Change: Quarterly Claim Editing Updates

Horizon Blue Cross Blue Shield of New Jersey works to ensure that our code and claim editing rules are accurate and consistent with standard business practice, which enables us to process claims efficiently and provide accurate reimbursement.¹

What to Know

Beginning in 2019, we will change the way we implement claim editing updates to help ensure that changes are applied in a more timely and efficient manner.

We will continue to announce upcoming quarterly code and claim editing rules updates on HorizonBlue.com/providernews. These online postings will continue to include details of the changes.

Horizon BCBSNJ will continue to process claims according to quarterly changes we announce following a period of no less than 30 days’ notice (“the implementation date”). Please note that within our claim processing systems, the effective dates of quarterly changes will reflect the first day of each respective quarter (i.e., January 1, April 1, July 1, October 1).²

How Claims Will be Processed

  • Claims for services provided on and after the first day of a quarter that are processed on or after an announced implementation date will reflect the quarterly changes announced.
  • Claims for services provided on and after the first day of a quarter that are processed prior to an announced implementation date will not reflect the quarterly changes announced.
  • Horizon BCBSNJ will NOT seek to adjust claims for services provided on and after the first day of a quarter that are processed prior to an announced implementation date.

    However, if a claim is adjusted following the implementation date of a quarterly update, and the claim is for a service provided on or after the first day of a quarter that was finalized prior to an announced implementation date, the claim will be processed based on the code and claim editing rules for that quarter.

Horizon BCBSNJ will continue to provide 90 days’ advance notice for the implementation of new and/or revised Horizon BCBSNJ administrative, medical and/or reimbursement policies that result in a material adverse change as outlined in our Material Adverse Change (MAC) Notification Policy. To access this administrative policy, please log in to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu and:

  • Mouse over References and Resources and click Provider Reference Materials
  • Mouse over Policies & Procedures and click Policies
  • Click Administrative Policies

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.

¹ We implement quarterly updates to help ensure that claims are processed using new and revised Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes, and that our claim editing rules and practices reflect the most current coding and code editing guidelines of nationally recognized sources including the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI), Outpatient Code Editor (OCE), and International Classification of Diseases Clinical Modification (ICD-CM).

² Codes may periodically be added to or deleted from our code auditing software and are not considered changes to the software version. In some cases, CMS may implement changes with an effective date prior to the first day of the quarter. Horizon BCBSNJ will not change or revise those industry-standard dates.

Clear Claim Connection

Participating physicians, other health care professionals and facilities can review how updated claim editing rules impact reimbursement for certain code combinations by using Change Healthcare’s Clear Claim Connection available via NaviNet®. To access Clear Claim Connection:

  • Log in to NaviNet.net and select Horizon BCBSNJ from the My Health Plans menu
  • Mouse over Claim Management
  • Click Clear Claim Connection.

Horizon BCBSNJ makes our Medical Policies, Administrative Policies, Reimbursement Policies and Guidelines and information about our Claim Editing Policies available on HorizonBlue.com/policies.

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

NaviNet® is a registered trademark of NaviNet, Inc.

Published on: October 2, 2018, 10:51 AM ET
Last updated on: October 15, 2018, 08:23 AM ET