Provider Outlier Program Frequently Asked Questions
Q. Which products are included or not included in the audit?
A. Only fully insured plans/programs are included in the audit. The following categories are excluded from this process:
- The New Jersey State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP)
- The Federal Employee Program ® (FEP ®)
- Medigap claims and secondary claims
Q. What claims are included in the audit?
A. The following criteria are subject to the audit:
- All high-level Evaluation and Management (E&M) services billed with or without a modifier
- Prolonged services and time-based E&M codes
- Modifiers associated with E&M services including, but not limited to, modifier 25
- Modifier 59 (XE, XS, XP and XU)
- Observation codes
- Telephone E&M services
Q. Can providers submit the claims and medical records electronically?
A. Yes. Providers must continue to submit claims electronically or to the appropriate mailing address.
Only copies of the medical records should be mailed to:
- Horizon BCBSNJ
- PO Box 140
- Newark, NJ 07101-0140
Providers should send the supporting medical records within a week of submitting the claim electronically. If the documentation is not provided, a denial for no medical records will be generated two weeks after the claim is received.
Q. How should the provider send in additional information/corrected claims/appeals?
A. The provider should mail corrected claims/appeals and/or additional information clearly marked together with the Horizon BCBSNJ Inquiry and Adjustment Form #579, found online at HorizonBlue.com/form579, to:
- Horizon BCBSNJ
- PO Box 140
- Newark, NJ 07101-0140
The provider may attach an Explanation of Payment (EOP) form, which can be found on NaviNet®, with the claim noted on a cover sheet.
Q. What information must be included in the medical record?
A. This information must be included in the medical record:
- Member's ID number
- Patient's name
- Date of service
- Physician group name
- Tax Identification Number (TIN)
Please include the patient’s name and identification number on all pages of the medical record.
Q. How can I identify claim denials from the audit?
A. Claims that are part of this audit will have the following claim denials:
- X945: Illegible record; missing information; code undocumented in medical record
- X946: No medical record provided = unsubstantiated services
- X947: Inappropriate use of override modifier
- X948: Medical record does not support CPT code billed
Other denial codes not listed above are not associated with the audit and should be resolved by calling Provider Services at 1-800-624-1110, weekdays, from 8 a.m. to 5 p.m., Eastern Time (ET).
Q. What if a provider has already sent in the medical record, but receives an X946 decline for medical records?
A. The audit may be in process. If the provider has sent the medical record to the address above in A.4., they may call Provider Services at 1-800-624-1110 two weeks after the medical record was sent to verify if it was received. An adjustment to the X946 decline is initiated based on the review of the received medical record.
Q. Can a provider submit more than one claim for services performed for a patient on the same day (split claims)?
A. No. Providers should submit one claim for all services performed for the patient on the same day.
Q. What is reviewed when a claim is identified for audit?
A. The whole claim is reviewed during this audit. Documentation for every line of the claim needs to be included. The provider is required to send in all documentation for all services billed on that claim for that date of service.
Q. How long is a provider in the prepayment audit?
A. A provider is in prepayment audit until less than 25 percent of the claims submitted contain errors for three consecutive months. This is not a 90-day audit.
Q. How is the error rate calculated?
A. The error rate is based on the number of claims and accompanying medical records submitted in a month that is reviewed by Horizon BCBSNJ. This includes claims submitted with medical records which pass the audit as well as those which receive X945, X947 and X948 denials.
The denial code X946 is not included in the error rate calculation since an audit has not yet been completed.
Q. What claims are not included in the error rate?
A. Claims that are not included in the error rate are:
- X946 declines for no medical records
- Claims for excluded plans/programs including SHBP, SEHBP, FEP and BlueCard
- Secondary claims
Q. Does this review include medical necessity?
A. It is not a medical necessity audit. This prepayment audit is only a coding audit. Providers must submit medical documentation that supports each CPT®/HCPCS code billed.
Q. What if I disagree with the final audit determination?
A. You may exercise your right to a Health Claims Authoriazaiton, Processing and Payment Act (HCAPPA) appeal.
CPT® is a registered trademark of the American Medical Association.
NaviNet® is a registered mark of NaviNet, Inc. The Federal Employee Program® and FEP® are registered marks of the Blue Cross and Blue Shield Association. Products are provided by Horizon Blue Cross Blue Shield of New Jersey, Horizon Insurance Company, Horizon Healthcare of New Jersey, Braven Health and/or Horizon NJ Health. Each company is an independent licensee of the Blue Cross Blue Shield Association. Communications may be issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all its companies. The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey. The Braven Health℠ name and symbols are a service mark of Braven Health.