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Quarterly Claim Editing Update: Third Quarter 2021

Horizon is updating our claim editing rules and processes for the third quarter of 2021 as noted below.

  • On July 1, 2021, we implemented claim editing updates related to rules/guidelines implemented by the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) that will impact claims for services provided to patients enrolled in fully insured, 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 web pages Quarterly PTP and MUE Version Update Changes and PTP Coding Edits.
     
  • On or about August 20, 2021, additional quarterly claim editing updates will include the NCCI edits noted above for all other members as well as the claim edits noted in our Quarterly Claim Editing Update Report.
     
    • The effective date of the changes noted in this report is July 1, 2021 (unless otherwise specified). Changes noted in this report will apply to all claims finalized on and after our implementation date.
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    • Claims finalized before this quarterly update is implemented will not be adjusted following the implementation for the sole purpose of ensuring conformity with these claim editing rules; however, if a claim that was finalized before the implementation is adjusted after the implementation for other reasons, the updated claim editing rules will be applied.

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™
Participating physicians, other health care providers and facilities 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™ and NaviNet® are registered trademarks of NaviNet, Inc.

Published on: July 21, 2021, 08:55 a.m. ET
Last updated on: July 20, 2021, 12:28 p.m. ET