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Reimbursement Policies to be Implemented

Horizon Blue Cross Blue Shield of New Jersey continues to enhance its claims auditing for professional and facility claims. Effective February 25, 2019, Horizon BCBSNJ will change the way we process certain claims based on the guidelines of the new reimbursement policies noted in the table below.

These new reimbursement policies will help ensure that the processing of claims for services provided to our members is in line with current standard business practices in regard to coding and billing rules and guidelines.

Member benefits will not be impacted by these new policies. In addition, claims submitted for services rendered prior to February 25, 2019 will not be impacted.

These new policies will be applied to professional claims for services provided to patients enrolled in:

  • Fully insured groups
  • ASO groups that opted in to these policy guidelines

We strongly encourage you to review the content of each policy below, in addition to the other policies, included in the Reimbursement Policies & Guidelines.

Reimbursement Policy Name
Ambulatory Electrocardiographic Monitoring
Cardiac Event Detection
Cardiovascular Implant Device Monitoring Services
Daily Maximum Units for Surgical Pathology and Microscopic Examination
Diabetic Screening Services
Duplicate Claim Logic for Independent Laboratory Services
Frequency of Care Coordination Services and ESRD Procedures
Frequency of G0179
Laboratory Services Billed by Physicians
Modifier 57
Modifier 76
Modifier 77
Pulmonary Diagnostic Procedures when billed with E&M Codes
Ulcer Debridement and Ulcer Stages

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for services on and after February 25, 2019.

Published on: November 26, 2018, 09:45 a.m. ET
Last updated on: April 27, 2021, 02:32 a.m. ET