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Reimbursement Policy Implementation - Outpatient Laboratory Claims: Referring Practitioner Required

Effective November 15, 2019 Horizon BCBSNJ will change the way we consider and reimburse certain clinical laboratory claims that do not include information about the referring practitioner based on the guidelines of our reimbursement policy, Outpatient Laboratory Claims: Referring Practitioner Required.

You can review the details of the Outpatient Laboratory Claims: Referring Practitioner Required reimbursement policy.


Based on the guidelines of this reimbursement policy, Horizon BCBSNJ will deny outpatient claims submitted by participating or nonparticipating clinical laboratories for services provided on and after November 15, 2019 if the referring practitioner information is not included.

To avoid claim outpatient clinical laboratory claim denials, include referring practitioner information as noted below: 

  • In 837P transactions please include referring practitioner information in Loop 2310A

  • On CMS  1500 claim forms (per the Medicare Claims Processing Manual Chapter 26 - Completing and Processing Form CMS-1500 Data Set), please include the following referring practitioner information

            Field 17.    Enter a “DN” qualifier (to denote Referring Provider), and Enter the referring provider name

            Field 17b.   Enter the NPI of the referring provider

To address claims denied for no referring practitioner information, clinical laboratories will have to submit a corrected claim that includes this required information. Until such time as this corrected claim information can be submitted and processed, members cannot be held liable for services related to these claim denials.

If you have technical questions about electronic transactions, please call our e-Service Desk’s EDI team at 1-888-334-9242, Monday through Friday, between 7 a.m. and 6 p.m., Eastern Time, or email an inquiry to HorizonEDI@HorizonBlue.com.

Unless Horizon BCBSNJ gives written notice that all or part of the above-noted changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after November 15, 2019.

Published on: August 14, 2019, 12:38 p.m. ET
Last updated on: August 15, 2019, 10:53 a.m. ET