Quarterly Claim Editing Update: Third Quarter 2018

Horizon Blue Cross Blue Shield of New Jersey will implement an update to our claim editing rules and processes for the third quarter of 2018. We encourage you to review details of this update with our Quarterly Claim Editing Update Report.

• Updates contained in this report will be implemented on or around August 1, 2018. These changes will be effective for dates of service on and after the specified Edit Effective Date for all claims finalized after the date on which we implement this update.¹

• Certain updates included within report section CHC Code Pair Additions and CHC Code Pair Expirations will be implemented on October 1, 2018.

Information about our Claim Editing Rules, including the guidelines we follow in regard to the advance notice we provide, is available online.

If you have questions, you can call 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.

¹Horizon BCBSNJ will not seek to perform adjustments of claims for services rendered between the first day of the quarter and the date on which we systemically implement a quarterly update that are finalized prior to our systemic implementation of that update solely for the purpose of that quarterly update. However, finalized claims that are adjusted for other reasons following a quarterly update implementation will be processed based on the guidelines included in that quarterly update.

Modifier Override Indicator Changes

With this quarterly update, Horizon BCBSNJ will align our approach with that of CMS regarding the implementation of modifier overrides included as part of CCI Changes and OCE CCI Changes. CMS applies retroactive effective dates to modifier override indicator changes on NCCI procedure-to-procedure (PTP) edits as part of CCI and OCE CCI changes (unless there is a reason for a more current effective date).

Horizon BCBSNJ processes claims using the guidelines in place at the time a claim is finalized. We will not seek to address retroactive modifier override effective dates by adjusting claims that were finalized prior to this quarterly update, however, if a finalized claim is adjusted for another reason following this implementation the modifier indicator rules in place at that time will be applied.

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 Clear Claim Connection available on NaviNet^®.

To access Clear Claim Connection, log in to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu and:

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

Clear Claim Connection^TM is a trademark of the Change Healthcare Corporation.