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Reimbursement Policy Update: Noncovered Related Services

Effective November 18, 2018, Horizon BCBSNJ will implement updates to our Noncovered Related Services reimbursement policy.

Based on the guidelines of this updated policy, Horizon BCBSNJ will change the way we consider and reimburse certain services determined to be related to a noncovered surgical service included on claims for services rendered on and after November 18, 2018.

We encourage you to review the guidelines of our updated Noncovered Related Services reimbursement policy.

Based on the guidelines of our Noncovered Related Services reimbursement policy, services provided by the same or a different practitioner/facility, on the same or a different claim, that are determined to be related to a noncovered surgical service will NOT be eligible for reimbursement if the diagnosis code(s) submitted on the claim in question are:

  • The same as, or similar to, the diagnosis code(s) included on the claim for the noncovered surgical service, and
  • The services in question are provided one day prior to, on the same day as, or within the five-day period following a noncovered surgical service.

The guidelines of our updated Noncovered Related Services reimbursement policy will apply to:

  • Services provided by a surgeon (or co-surgeon/assistant surgeon if billing with the same Tax ID Number as the primary surgeon) on the day prior to, on the same day as, or within the five-day period following, a noncovered surgical service
  • Evaluation and Management services related to and provided by the surgeon (or co-surgeon/assistant surgeon) on the same day as a noncovered surgical service
  • Pre-operative testing services related to and rendered by any provider on the same day as a noncovered surgical service
  • Anesthesia services related to and rendered by any provider on the same day as a noncovered surgical service
  • Pathology services related to and rendered by any provider on the same day as a noncovered surgical service
  • Radiology services related to and rendered by any provider on the same day as a noncovered surgical service
  • Outpatient facility services related to and provided on the same day as a noncovered surgical service

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 18, 2018.

Published on: August 17, 2018, 12:35 p.m. ET
Last updated on: August 17, 2018, 12:38 p.m. ET