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Claim Editing Policies

If our claim processing system does not recognize information on a claim, the claim is manually reviewed. The claim is then reviewed for medical eligibility based on our medical policy guidelines.

Our claim policy department will review all required medical documentation from you and determine if further review from the Medical Advisor's Office is necessary.

Significant Claim Edits
A significant claim edit is an edit that Horizon Blue Cross Blue Shield of New Jersey reasonably believes, will cause the denial or reduction in payment for a particular CPT® Code or HCPCS Level II Code more than two-hundred and fifty (250) times per year on the initial review of submitted claims.

General Edit Description
Additional Service, Missing Primary Service The service reported was not reported in conjunction with a required primary service.
Age The service reported was inappropriate for the patient's age.
Assistant at Surgery Reduction Assistant at surgery is reimbursed for services in accordance with their degree of responsibility for the surgery.
Benefit The service either was not covered or exceeded the coverage limitations of the member's benefits.
Bundled Procedure When these services are covered, payment for these services are bundled into another service to which they are incident.
Co/Assistant Surgeon Not Allowed A co-surgeon and/or assistant surgeon are not eligible for the service submitted.
COB Service must be submitted to the member's primary coverage.
COB Paid Primary coverage has paid the service in full.
Contracting Limitations The service was reduced or denied based on the terms of the physician's or health care professional's contract.
Diagnosis/CPT Matching The service was invalid for the diagnosis reported.
Duplicate/Similar Service There was a duplicate or similar service that was previously reported for the patient for the same date of service.
Eligibility According to Horizon BCBSNJ's records, the patient was not eligible for coverage on the date the service was performed.
Gender The service reported was inappropriate for the patient's gender.
Global Period Payments for services associated with a surgical procedure are included in a single payment for services that fall within the specified date range (a/k/a global surgical package).
Inappropriate Use of Modifier The service was missing the appropriate modifier or was reported with an incorrect modifier.
Incomplete/Incorrect Claim Data The information on the claim was incomplete or incorrect.
Insufficient Information to Process Service There was insufficient information supplied with the claim to appropriately process the reported service.
Invalid Code The service code reported was not valid.
Invalid Date Range Submitted on Claim The date range on the claim is inconsistent or invalid.
Medical Necessity The service reported did not meet medical necessity requirements.
Medical Policy The reimbursement for the service was reduced or denied due to failure to meet Medical Policy guidelines.
Medicare/CMS Guidelines The service was not covered under Medicare/CMS guidelines.
Multiple Procedure When multiple procedures are performed on the same day, on the same patient, the subsequent procedure(s) are paid at a lesser amount than the primary procedure.
Multiple Radiology Reduction When two or more radiological services are performed on the same region, of the same patient, on the same day, the second and subsequent services will receive a reduced reimbursement.
Multiple Surgery Reduction When multiple surgeries are performed on the same day, on the same patient the subsequent surgeries are paid at a lesser amount than the primary surgery.
Mutually Exclusive Combination of procedures that differ in technique or approach but lead to the same outcome, may be anatomically impossible or represent overlapping services, the lesser procedure is denied.
Other Coverage The patient was not insured by Horizon BCBSNJ.
Cannot Bill Outpatient & Inpatient on the Same Day Outpatient services cannot be billed on the same day a patient was admitted for inpatient services.
Place of Service The service reported was inappropriate for the place of service indicated on the claim.
Pre-Determination An approved Pre-Determination was required prior to performing this service.
Pre-Existing Condition The service is not covered because it was related to a pre-existing condition.
Prior Authorization Required An approved Prior Authorization was required prior to performing this service.
Provider Adjustment An adjustment was made based on contracted rates.
Referral Required A referral from the patient's PCP was required prior to performing this service.
Second Opinion Required The member was required to obtain a second opinion prior to performing this service.
Service Unit Maximum The service exceeds the maximum number of units eligible for reimbursement.
Specialty Not Eligible The service reported was invalid for the health professional's specialty.
Timely Filing The service was submitted after the timely filing deadline.
Type of Service The service reported was inappropriate to the type of service indicated on the claim.
Un-Bundling When these services are covered, they should be reported as separate services.

Subsequent or Similar Services performed on the same day
If a physician, hospital, or vendor submits a claim with services following a primary service and these subsequent services are billed for the same date of service as the primary service, then the actual claim is reviewed to verify the billing, and the subsequent service lines are adjudicated at percentages of the primary service line.

Commercially Available Claim Editing Systems
Horizon Blue Cross Blue Shield of New Jersey uses the following commercially available claim editing systems:

Claim Editing Systems Customized
McKesson ClaimsXten® 5.02/CCI 22.3 YES
McKesson ClaimCheck® release 8.5 and Knowledge Base version 45 NO
TriZetto® ClaimFacts® version 6.71 NO
TriZetto® QNXT version 3.2SP15CP006 NO
Bloodhound Technologies (for AtlantiCare claims only) NO

PROFESSIONAL RULES
The ClaimsXten® Knowledge Packs effective on December 17, 2010 are:

  1. ClaimsXten Core Knowledge Pack
    1. Invalid Age for Procedure Code Edits
    2. Invalid Gender for Procedure Code Edits
    3. Modifier to Procedure Code Validation Edits
    4. Invalid Procedure Code Edits
  1. Code Auditing Knowledge Pack
    1. Assistant Surgeon Eligible Policy
    2. Frequency Validation/Alternate Code Edits
    3. McKesson Multiple Code Rebundling Edits
    4. CMS Correct Coding Initiative (CCI) Edits
    5. Global Surgery Period Edits (Pre/Post Op, Same Day Visit
    6. Multiple Units/Frequency Validation Edits
    7. McKesson Unbundling Edits
  1. Core Auditing Add-on Knowledge Pack
    1. Add-on Procedure Code without Base Code edit
    2. Missing Professional Component Modifier-26 edit
  1. ClaimsXten Custom Rules
    1. Multiple Site Specific Modifiers
    2. Quantity Date Span.
  1. Other ClaimsXten Logic
    1. Multiple Surgery Procedures
    2. Multiple Radiology Procedures

The ClaimsXten® Knowledge Pack updates effective August 8, 2011 are:

  1. Code Auditing Premium
    1. ASA Anesthesia Not Eligible
    2. ASA Anesthesia Multiple Crosswalk
    3. ASA Anesthesia Standard Crosswalk

The ClaimsXten® Knowledge Pack updates effective Sept 5, 2011 are:

  1. Core Auditing Add-on Knowledge Pack:
    1. Global and Technical/Professional Component Billing Edits
    2. Bilateral Rule

The ClaimsXten® Knowledge Pack updates effective November 18, 2011 are:

  1. Core Auditing Add-on Knowledge Pack:
    1. Incomplete Diagnosis
    2. Invalid Diagnosis

The ClaimsXten® Knowledge Pack updates effective December 19, 2011:

  1. Core Auditing Add-on Knowledge Pack:
    1. Base Code Quantity

The ClaimsXten® Knowledge Pack updates effective April 16, 2012:

  1. Core Auditing Add-on Knowledge Pack:
    1. Lab Panel

The ClaimsXten® Core Knowledge Pack updates effective September 09, 2012:

  1. Deleted Code
  2. Female Specific Diagnosis
  3. Male Specific Diagnosis

The ClaimsXten® Core Knowledge Pack updates effective October 29, 2012:

  1. Supplies Same Day Surgery Inclusive
  2. Outpatient Consultations
  3. Inpatient Consultations
  4. Obstetrics Package Rule
  5. CMS Always Bundled Procedures (see the section Accessing the list of CMS Always Bundled Procedures below)

The ClaimsXten® Knowledge Pack updates effective April 15, 2013:

  1. Code Auditing Premium:
    1. New Patient Code for an Established Patient
  1. Waste and Abuse:
    1. CPAP BIPAP Supply Frequency
    2. Diabetic Supply Frequency

The ClaimsXten® Knowledge Pack updates effective April 20, 2014:

Code Auditing Premium:

  1. Global Component

The ClaimsXten® Knowledge Pack updates effective June 03, 2018:

  1. Pay Percent Multiple Cardiology 
  2. Pay Percent Multiple Ophthalmology
  3. Pay Percent Multiple Therapy (only applies to Non-Par therapists)

OUTPATIENT FACILITY RULES

The ClaimsXten® Knowledge Pack updates effective December 19, 2011 are:

  1. ClaimsXten Core Knowledge Pack:
    1. Age (Facility)
    2. Gender (Facility)
    3. Incomplete Diagnosis
    4. Diagnosis Invalid
    5. Procedure Invalid
    6. Procedure Modifier Validation
    7. Outpatient Code Editor (OCE edits)

The ClaimsXten® Knowledge Pack updates effective April 16, 2012:

  1. ClaimsXten Core Knowledge Pack:
    1. Lab Panel

The ClaimsXten® Core Knowledge Pack updates effective September 09, 2012:

  1. Deleted Code
  2. Female Specific Diagnosis
  3. Male Specific Diagnosis

The ClaimsXten® Core Knowledge Pack updates effective October 29, 2012:

  1. Horizon Medical Policy Rule

The ClaimsXten® Core Knowledge Pack updates effective April 20, 2014:

  1. Global Component

The ClaimsXten® Knowledge Pack updates effective November 30, 2014:

  1. Facility MUE (Medically Unlikely Edits)
  2. McKesson’s Outpatient Unbundled Pairs – applies to non-participating facilities only

Accessing the list of CMS Always Bundled Procedures
You may view a list that identifies CMS Always Bundled Procedures on the CMS website. Please follow the steps listed below to access this information.

  1. Visit www.cms.gov and click Medicare.
  2. Click Physician Fee Schedule under the Medicare Fee-for-Service Payment heading.
  3. Click PFS Relative Value Files from the options within the left navigation menu.
  4. Select the appropriate year and release. Please note: CMS will display multiple records for a given year based on the number of releases. Horizon BCBSNJ updates our files on a quarterly basis.
  5. Open the ZIP file within the Downloads section.
  6. Within the ZIP file folder, open the desired PPR RVU file (.xlsx, .csv or .txt extension).
  7. Locate the code in question and review the value within the Status Code column. A value of "B" in the Status Code column indicates a code that is always bundled. Helpful hint: To make it easier to view all CMS "B" codes, re-sort this file by the Status Code column.

Echocardiogram Procedures Billed With an E&M Service
Beginning on December 15, 2010, to prevent duplicate or erroneous billing issues, Horizon BCBSNJ updated our claims auditing software to apply incidental service coding logic to echocardiogram services when these services were billed with an inpatient Evaluation & Management (E&M) service on the same date of service for the same patient.

Since that time, we considered echocardiogram/inpatient E&M service code pair combinations for separate reimbursement if modifier 25 was appended to the E&M service code or if modifier 59 was appended to the echocardiogram code.

Effective October 1, 2012, Horizon BCBSNJ will no longer consider echocardiogram/inpatient E&M service code combinations appended with modifiers 25 or 59 for separate reimbursement.