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Reimbursement Policy to be Implemented: Maximum Units for Anesthesia

Effective December 14, 2020, Horizon BCBSNJ will change how we consider and reimburse certain professional claims for anesthesia services based on the guidelines of our new reimbursement policy, Maximum Units for Anesthesia.

Per the guidelines of this policy the number of units submitted for CPT® codes 00100 through 01999 included on claims for services rendered on and after December 14, 2020 will be reviewed systemically. Units billed in excess of an established maximum number of units for a given procedure code will be denied. The maximum number of units were established based on claims submitted by the vast majority of providers performing the procedures in question.

Participating providers may not seek payment from our members for anesthesia units denied with the Explanation of Payment message: K821: The maximum number of units allowed for this service is exceeded.

This policy will apply to patients enrolled in Horizon BCBSNJ:

  • Fully insured commercial plans,
  • Medicare Advantage plans
  • New Jersey State Health Benefits Program/School Employees’ Health Benefits Program (SHBP/SEHBP) plans.

Administrative Services Only (ASO) employer groups may opt-in to the guidelines of this policy.

Exceptions to the above shall be made on a case-by-case basis or on appeal based on the specific circumstances involved in the case.

We strongly encourage you to review the content of our Maximum Units for Anesthesia reimbursement policy,

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

Published on: September 15, 2020, 02:53 a.m. ET
Last updated on: June 23, 2021, 10:34 a.m. ET