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Quarterly Claim Editing Update: First Quarter 2023

We are updating our claim editing rules and processes for the first quarter of 2023 as noted below.

  • On January 1, 2023 we implemented claim editing updates related to rules/guidelines implemented by the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI). The updates impact claims for services provided to patients enrolled in fully insured commercial, Medicare Advantage and State Health Benefits Program/School Employees' Health Benefits Program (SHBP/SEHBP) plans.

    Details of these updates may be accessed by visiting CMS' Quarterly PTP and MUE Version Update Changes and PTP Coding Edits.

  • On or about February 17, 2023, additional quarterly claim editing updates will be implemented. These edits include the NCCI edits noted above for patients enrolled in plans not referenced above as well as the claim edits noted in our First Quarter 2023 Claim Editing Update Report.

    Unless otherwise specified in the report, the changes noted in the report will impact services rendered January 1, 2023 and after that are included on claims that are finalized February 17, 2023 and after.

    Claims that are finalized before February 17, 2023 will not be adjusted solely for the purpose of ensuring conformity with these claim editing rules. However, if we adjust a claim for another reason after February 17, 2023 that was originally processed before February 17, 2023, the updated claim editing rules will be applied to the codes within that claim.

Read more about our Claim Editing Policies.

If you have questions, call Provider Services at 1-800-624-1110 or Institutional Services at 1-888-666-2535, weekdays, between 8 a.m. and 5 p.m., Eastern Time.


Clear Claim Connection™

You can review how updated claim editing rules impact reimbursement for certain code combinations by using the 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.

Clear Claim Connection™ is a registered trademark of ClaimsXten Portfolio.
NaviNet® is a registered trademarks of NaviNet, Inc.

Published on: January 18, 2023, 01:00 a.m. ET
Last updated on: January 19, 2023, 07:43 a.m. ET