Claim Reimbursement
Reimbursement for claims submitted to us for services provided to our members are made to providers in one of the two methods noted below. Click the reimbursement methods below for information.
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- HEDIS Resources
- Claim Submission & BillingClaim Submission & Billing
- Billable Service Exceptions Billable Service Exceptions
- Claim Editing Policies
- Claim Reimbursement
- Claim Submission Claim Submission
- Electronic Claim Adjustments
- Explanation of Payment
- PCP Billable Lists
- Pre-payment Correct Coding Reviews
- Prompt Pay Guidelines
- Demographic UpdatesDemographic Updates
- The Importance of Demographic Updates
- Provider Directory Management Policy
- CMS Audits to Validate Directory Information
- Initiating Demographic Updates: Participating Providers Initiating Demographic Updates: Participating Providers
- Supporting Documentation Requirements for Practice-level Demographic Updates
- Supporting Documentation Requirements for Practitioner Demographic Updates
- Supporting Documentation for Ancillary Provider Demographic Updates
- Initiating Demographic Updates: Nonparticipating Providers
- Inquiries, Complaints & AppealsInquiries, Complaints & Appeals
- Inquiries
- Complaints
- Time Limits for Filing Inquiries/Complaints
- Resolving Inquiries/Complaints
- Appeals of Non-Utilization Management Determinations
- Appeals of Utilization Management/Medical Management Determinations
- Appeals of Post Service Medical Necessity Determinations
- PoliciesPolicies
- Medical Policies Medical Policies
- Allied Health
- DME
- Drugs
- Introduction
- Medicine
- Obstetrics
- Pathology
- Radiology
- Surgery
- Treatment
- MCG Care Guidelines
- Documentation Submission Guidelines
- Administrative Policies Administrative Policies
- Allowable Practice Locations for Pathologists
- Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns, Specialists and Behavioral Health Providers
- Credentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) Providers Credentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) Providers
- Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals
- Diagnostic Imaging Privileging by Participating Provider Practice Specialty
- Digital Member ID Card Policy
- EDI and NaviNet Claims Submission Requirement
- Electronic Funds Transfer (EFT)
- Material Adverse Change (MAC) Notification Policy
- Medical Records Documentation Standards
- Medicare Advantage Readmission
- Never Events
- Out-of-Network Referral Policy
- Outlier Audit Programs: Post Payment and Pre-Payment
- Physician and Healthcare Professional Counseling and Termination Policy - Professional Competency
- Participation Status in Products that Utilize Tiering and/or Subset of an Existing Horizon Network
- Pass Through Billing (Modifier 90)
- Practice Location Reinstatements
- Practice Locations Limit
- Practitioner Office Site Quality and Medical/Behavioral Health Record Keeping Standards
- Provider Directory Management
- Provider Outlier Program Frequently Asked Questions
- Retainer Based Medicine
- SHBP/SEHBP Inpatient Readmission Reimbursement
- Standards for All Types of Medical and Dental Diagnostic Radiology and Imaging Facilities
- Tier Awareness Policy
- Use of Horizon Hospital Network Performance Data
- Use of Practitioner Performance Data
- BlueCard Medical Policies
- Reimbursement Policies & Guidelines Reimbursement Policies & Guidelines
- Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)
- After-hours and Weekend Care
- Ambulance Services
- Ambulatory Electrocardiographic Monitoring
- Anesthesia Reimbursement Guidelines
- ASC Multiple Procedure Methodology
- Assistant at Surgery
- Balloon Sinuplasty
- Bariatric Surgery Billed With Hiatal Hernia Repair
- Behavioral Health Services Rendered by Supervised Practitioners
- Bilateral Procedures
- Billing Guidelines for Maternity Services
- Biologics Coding
- Cardiac Event Detection
- Cardiovascular Implant Device Monitoring Services
- Casting, Strapping and Splints
- Chemotherapy Administration
- Chronic Care Management Services
- Claim Editing Policies
- Claims Requiring Additional Documentation
- ClaimsXten Editing Rules
- Clinical Trials Support Program
- Co-Surgeon Reimbursement
- Collaborative Care Management Services
- Colonoscopy with Modifier 59
- Conscious Sedation
- Consultation Services Payment
- Consumable Medical Supplies
- Continuous Positive Airway Pressure or Bi-level Positive airway Pressure (CPAP/BiPAP) Supplies
- COVID 19 Antibody Testing
- COVID-19 Testing and Testing Related Services
- Daily Management of Epidural or Subarachnoid Continuous Drug Administration
- Daily Maximum Units for Surgical Pathology and Microscopic Examination
- Determination of Refractive State
- Diabetic Screening Services
- Diabetic Supplies
- Distinct Procedural Service Modifiers (59, XE, XP, XS, XU)
- DME Rent to Purchase
- Drug and Immunization Pricing
- Duplex Scanning
- Drug Wastage – Modifier JW
- Duplicate Claim Logic for Independent Laboratory Services
- Evaluation and Management Services with Chiropractic Manipulative Treatment
- Evaluation and Management Services with Osteopathic Manipulative Treatment
- Evaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo, Myocardial Profusion Imaging
- False Claims
- Free Flap Breast Reconstruction
- Frequency of Care Coordination Services and ESRD Procedures
- Frequency of G0179
- Hip Arthroscopy
- Horizon Fee Schedule Updates based on Third Party Sources
- Hospital Non-Patient Laboratory Services Hospital Non-Patient Laboratory Services
- Hot or Cold Pack Therapy
- Inpatient Consultations
- Knee Arthroscopy
- Lab Panel Rebundling
- Laboratory Services Billed by Physicians
- Laser Treatment of Psoriasis or Parapsoriasis
- Maternity Reimbursement
- Maximum Units for Anesthesia
- Medical Nutrition Therapy (MNT)
- Medicare Advantage Hospital Sequestration Reimbursement
- Microsurgery and Robotic Surgery
- Modifier 25
- Modifier 50 Bilateral Guidelines
- Modifier 52
- Modifier 53
- Modifier 54
- Modifier 55
- Modifier 56
- Modifier 57
- Modifier 76
- Modifier 77
- Modifier 78
- Modifier SU
- Modifiers CQ/CO
- Multiple Procedure Reductions
- Mutually and Non-Mutually Exclusive NCCI Supplemental Edits
- Non-ESRD ESA Level Reporting
- Noncovered Related Services
- Outpatient Consultations
- Outpatient Facility Code Edits: Bundling and Revenue Codes Outpatient Facility Code Edits: Bundling and Revenue Codes
- Bundled Services
- Lab codes when billed with other services
- Revenue Codes Requiring HCPCS Codes
- Typically packaged codes
- Outpatient Laboratory Claims: Referring Practitioner Required
- Outpatient Therapy Daily Maximum
- Physician Extenders Non-Surgical Services
- Pre-Admission Testing
- Pre-Payment Coding Reviews Documentation Requests
- Pre-Payment Documentation Requests: Facility Claims
- Post Payment Documentation Requests: Facility Claims
- Pulmonary Diagnostic Procedures when billed with E&M Codes
- Radiology, Preliminary and Double Reads
- Radiopharmaceuticals
- Reimbursement and Billing Guidelines for Anesthesia Claims
- Removal of Impacted Cerumen Requiring Instrumentation
- Screening and Diagnostic Mammography & 3D Tomosynthesis
- Site of Service Differential
- Smoking Cessation
- Status N Codes
- Telemedicine Services Telemedicine Services
- Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon BCBSNJ Commercial/ASO plans and products
- Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon Medicare Advantage
- Ulcer Debridement and Ulcer Stages
- Urgent Care Center Billing Requirements
- Urinalysis with Evaluation and Management (E&M) Services
- Urine Drug Screening/Testing
- Vascular Coding
- Vitamin D Testing
- Utilization ManagementUtilization Management
COVID-19
Stay informed.
Get the latest information on COVID-19.
Get the latest information on COVID-19.