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Quarterly Claim Editing Update: 2nd Quarter 2017

Horizon Blue Cross Blue Shield of New Jersey will implement a quarterly update to our claim editing rules and processes. Please review our Quarterly Claim Editing Update Report that identifies the changes that will be implemented as noted below.

  • On May 1, 2017 we will implement the claim editing rules identified in the report that will enable us to process claims in accordance with nationally recognized coding and code editing changes.

    Changes include those that have already been implemented by the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (CCI), Outpatient Code Editor (OCE), American Medical Association (AMA) Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases Clinical Modification (ICD-CM).
  • On July 1, 2017 we will implement the claim editing rules identified in the report that reflect McKesson's ongoing review of current claim processing/claim editing practices.

    These claim editing changes are based on recommendations of various medical societies and organizations, medical policy and literature research and standards, and input from academic affiliations. Changes may also reflect the implementation of new and/or revised Horizon BCBSNJ administrative, reimbursement and/or medical policies.

Claims that are processed on and after the above noted implementation dates will follow those updated adjudication rules. Horizon BCBSNJ reserves the right to adjust claims for services provided on and after one of the noted implementation dates above that do not follow our updated claim editing rules.

Additional information about our Claim Editing Policies is available online.

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


McKesson’s ClaimsXten

We work with McKesson, the oldest and largest health care services company in the nation, and use McKesson’s ClaimsXten, a clinically based claims editing solution, to help ensure that our code and claim editing rules are accurate and consistent with standard business practice to enable us to process claims efficiently and provide accurate reimbursement.

We work with McKesson to carry out quarterly ClaimsXten updates that include changes based on McKesson’s ongoing review of current claim processing/claim editing practices, incorporating guidelines from industry-standard and essential clinical coding sources, as well as the implementation of new and/or revised Horizon BCBSNJ administrative, reimbursement and/or medical policies.


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 the McKesson Clear Claim Connection available via NaviNet®.

To access Clear Claim Connection, log in to NaviNet.net, select Horizon BCBSNJ Plan Central and:

  • Mouse over Claim Management.
  • Click Clear Claim Connection.

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

Published on: March 30, 2017, 15:31 p.m. ET
Last updated on: March 30, 2017, 15:35 p.m. ET